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SURGICAL AND OBSTETRICAL 
OPERATIONS 



W. L. WILLIAMS 



Professor of Surgery and Obstetrics in the New York State 
Veterinary College, Cornell University 



Embodying portions of the QPERATIONSCURSUS of Dr. Pfeiffer, 

Professor of Veterinary Science in the 

University of Giessen 



THIRD EDITION, REVISED AND ENLARGED 



1912 
. CARPENTER & COMPANY 
ITHACA. N. Y. 



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Copyright, 1912 

BV 

CARPENTER & CO. 



Press of 

Andrus & Church 

Ithaca, N. Y. 



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PREFACE TO THE THIRD EDITION. 

The author caused to be published in 1900 a booklet 
entitled : " A Course in Surgical Operations by \V. Pfeiffer 
and W. L. Williams," consisting of an authorized transla- 
tion of Dr. Pfeiffer' s Operating-Cursus with such changes. 
additions and omissions as were deemed desirable. Three 
years of constant use. with such criticisms as came to the 
author from others, served to point out desirable changes 
of so sweeping a character as to demand a practical!}' new 
treatise specially adapted to American conditions, and to 
render the continuance of a formal joint authorship inex- 
pedient and in 1903 the author published a more extended 
volume under the present title, followed by a large second 
edition in 1906. In this third edition the author has con- 
tinued to draw freely upon Dr. Pfeiffer' s Operations-Cursus 
in the preparation of the text which in many chapters is 
practicalh' copied therefrom, including the illustrations with 
grateful acknowledgement of his profound obligations. On 
the other hand nothing has been copied or extracted except 
it could be freely adopted as the author's own view, releas- 
ing Dr. Pleiffer from all responsibility for the character 
of any of the contents. 

The volume is primarily designed for the use of the au- 
thor's classes in laboratory surgery and embryotomy in which 
the student performs the surgical operations described, on 
animals procured for the express purpose, under chloroform 
anaesthesia whenever possible, after which the subject is 
destroyed while still anaesthetized ; at the same time it has 
been aimed to render the volume of the greatest possible 
value to the practitioner consistent with this plan. The 
operations included under this scheme are necessarily limited 
to those which can be reasonably well performed on com- 
paratively sound animals of little value and regularly pro- 
curable for laboratory purposes. The list covers a wide 



IV 



PREFACE TO THE THIRD EDITION, 



range and is designed to give to the student as thorough 
training as is practicable in a laboratory course and includes 
well nigh all the more important varieties of confinement, 
anaesthesia, disinfection, sutures, bandaging, dressing and 
other adjuncts to operative work. The chapter on trephin- 
ing of the facial sinuses has been dealt with at much greater 
length in the present edition in order to fully and clearly 
describe the author's method of operating. 

The operation for the surgical relief of roaring in horses 
has undergone a complete revolution since the publication 
of our second edition in 1906 and the technic therefor which 
we had begun to develop in 1905 and tentatively inserted 
in the second edition has undergone phenomenally rapid 
changes until now it would appear that the technic had 
acquired a certain degree of permanency, though still too 
new to expect it to remain unchanged. The introduction 
of the ventricular burr by Dr. J. H. Blattenberg and various 
suggestions in the details of technic by Prof. Hobday of 
England and others has materially aided in bringing the 
operation to its present state of reliability and caused the 
operation introduced by us in 1905 to become accepted 
throughout America and Europe to the exclusion of other 
methods. We have accordingly omitted the chapter on 
arytenectomy from this edition, as an obsolete operation 
and have inserted an entirely new chapter upon the opera- 
rion for roaring in which we have endeavored to bring the 
technic thoroughly up to date. 

Generally but one method of operating is described, the 
one chosen being that which in the author's experience has 
proven the most valuable in actual practice, and no opera- 
tion has been introduced purely for practice but each one 
has been tested and known to have practical value. 

When two methods of operating are given, they are 
inserted because each has definite points of superiority over 
the other and one method may be specially applicable in a 



PREFACE TO THE THIRD EDITION. y 

given case, another in a different patient where the same 
operation is to be performed as for example, a milk cow is 
best spayed through the vagina while a heifer must be 
operated upon by an incision through the abdominal walls. 

Considerable stress has been laid upon the surgical anato- 
my of the parts involved in each operation ; some uses of 
the various operations are mentioned ; some of the chief 
dangers of each are pointed out and in some cases references 
to literature upon the operation or the diseases for which 
the operation is designed, are cited. 

Figures i, 2, 6, 7, 9, 10, 11, 15, 16 and 17 and Plates Nos. 
XII, XIV, XVI, XXIII, XXIV, XXVII, XXVIII, 
XXIX, XXXI, XXXIV, XXXV, are from Dr. Pfeiffer's 
Operations-Cursus ; and the remaining Plates and figures 
were either drawn under the direction of the author by 
Mr. C. W. Furlong, formerly instructor in Industrial Draw- 
ing and Art in Sibley College, Cornell University, or were 
made from original photographs. 

W. ly. WiLIwIAMS. 

Cornell University, March, igi2. 



CONTENTS. 

I. 

I. OPERATIONS ON THE HEAD : 

Page. 

Extraction of Teeth i 

Repulsion of Teeth 8 

Trephining the Facial Sinuses 16 

Trephining of the Frontal Sinuses 19 

Trephining the Superior Maxillary Sinuses 32 

Trephining the Inferior Maxillary Sinuses 41 

Trephining the Nasal Fossae 45 

Poll Evil Operation 53 

Ivigation of the Parotid Duct 61 

Entropium Operation 62 

Staphylotomy 63 

Trifacial Neurotomy 64 

II. OPERATIONS ON THE NECK : 

Opening the Guttural Pouches 70 

Tracheotomy 76 

The Operation for Roaring 78 

Intra-tracheal Irrigation 87 

Intravenous Injection 88 

a. Phlebotomy with Fleams 91 

b. Phlebotomy with Lancet 92 

c. Phlebotomy with Trocar 93 

Ligation of the Carotid Artery 93 

CEsophagotomy 98 

III OPERATIONS ON THE TRUNK AND ON THE GENITAI, ORGANS : 

Puncture of the Chest 100 

Puncture of the Intestine 10 1 

Subcutaneous Caudal Myotomy 103 

Caudal Myectomy for Gripping of the Reins 105 

Amputation of the Tail 109 

Urethrotomy 114 

Amputation of the Penis 117 

Vaginal Ovariotomy in the Mare 123 

Vaginal Ovariotomy in the Cow 130 

Ovariotomy in the Cow by the Flank 133 



CONTENTS vii 

Ovariotomy in the Bitch by the Flank 134 

Ovariotomy in the Bitch by the Linea Alba 141 

Ovariotomy in the Cat 142 

Castration of Cryptorchid Horses 143 

IV. OPERATIONS ON THE EXTREMITIES : 

Tenotomy of the Flexor Tendons of the Foot 154 

Tenotomy of the Peroneal Tendon (Stringhalt Operation) 157 

Tenotomy of the Cunean Tendon (Spavin Operation) 159 

Neurotomy 161 

Digital Neurotomy 167 

Plantar Neurotomy 169 

Median Neurotomy 174 

Ulnar Neurotomy 179 

Sciatic Neurotomy 185 

Anterior Tibial Neurotomy 191 

Resection of the Lateral Cartilages 196 

Resection of the Flexor Pedis Tendon 202 

Amputation of the Claws of Ruminants 204 

Bayer's Sutures 209 

II. 

EMBRYOTOMY OPERATIONS : 

Cephalotomy 212 

Decapitation 214 

Subcutaneous Amputation of Ant^irior Limb 215 

Amputation at the Humero-radial Articulation 218 

Detruncation 218 

Destruction of the Pelvic Girdle, Anterior Presentation 222 

Amputation of the Limbs at the Tarsus 226 

Intra-pelvic Amputation of the Posterior Limbs, Breech Pre- 
sentation 230 

Evisceration of the Fetus 239 



INTRODUCTION. 

Man}^ details must be omitted in the succeeding text which 
are of importance in each operation, but which, if inserted, 
would render the volume unwieldy in size for the purpose 
designed. 

These details are in a measure alike in each case, and it is 
assumed that the student has already familiarized himself 
with them. The more important of these may be summa- 
rized as follows : 

1. The subject should be securely confined in each case 
as directed, because the method designated has been found 
effective in the operation under description, and serves to fix 
the relations of the parts in such a way as to conform to the 
surgical anatomy of the region as outlined in the text. It 
is to be constantly borne in mind that a change in the atti- 
tude of the animal may cause profound alterations in the 
relations of parts which displacement may greatly embarass 
the operator, or even prevent his carrying out the operation 
according to the technic given. In securing an animal for 
operation the whole body should be confined in a way that 
will sufficiently control movements and will insure safety to 
the patient and operator ; the part to be operated upon must 
be so fixed as to properly limit its motion and in a position 
to afford the greatest facility for the carrying out of the 
operation according to the technic given. 

2. Anaesthesia should be carefully carried out everywhere 
possible, because in addition to the humane sentiments in- 
volved, the resulting perfect control of the animal is an 
essential in aseptic or antiseptic surgery. The student 
should make a careful study of anaesthesia in these exercises 
and acquire invaluable experience and confidence for their 
use in actual practice. 



X INTRODUCTION. 

3. Disinfection must be scrupulously applied in every de- 
tail since upon its effectiveness must rest the verdict of 
success or failure as measured by modern surgical thought. 
The operator's finger nails should be well trimmed, smoothed 
and cleansed, and his hands and arms thoroughly scrubbed 
with a stiff brush in hot water and soap for a period of fifteen 
minutes, and all dirt and old epidermal scales removed. 
The parts should then be disinfected. This may be accom- 
plished by immersing the hands in a hot concentrated solu- 
tion of permanganate of potassium for ten minutes and then 
decolorizing them in a strong solution of oxalic acid in boiled 
water. 

Or the hands may be disinfected after the washing with 
soap and water by immersing and scrubbing them for ten 
minutes in a i to 1000 solution of corrosive sublimate, but 
in order to make this thoroughly effective the solution needs 
be alcoholic, or the hands should first be immersed in 
alcohol, ether, or other substance capable of dissolving fats 
and permitting the disinfectant to penetrate to every part 
without being obstructed by sebum or fat. Great care 
should be exercised by the student not to touch any object 
with his hands after they have been disinfected for the 
operation, unless such object has also been disinfected or 
sterilized, or in case it becomes necessary to touch objects 
not sterile, the disinfecting process should be repeated before 
proceeding further with the operation. This constitutes 
one of the most difficult of all details for the beginner to 
acquire, and each failure should be remedied by repeating 
the process over and over until the habit of maintaining 
effectual asepsis is acquired and fixed. 

The operative field should always be carefully shaved be- 
fore beginning the operation, and the shaved area should 
always be ample, so as to insure against contamination 
from adjacent hairs, as well as to give a clear view of the 
field. The area should then be disinfected in a reliable 



INTRODUCTION. xi 

manner, that advised for the operator's hands serving as a 
type. Whenever circumstances will permit the operative 
field should be kept in an antiseptic bath or pack for twenty- 
four hours prior to the operation in order that the deeper 
parts of the skin, especially the hair follicles and sebaceous 
glands, shall become thoroughly disinfected, a process well 
nigh impossible in a short period. 

The suturing, dressing and bandaging of the wound 
should be carried out carefully in every case and no opera- 
tion left without completing it in the best manner possible. 

The student should make each operation as real as possible 
and not omit any detail even if he thinks he already knows 
it sufficiently well, as the repetition of a supposedly familiar 
detail serves an important purpose in the fixing of a habit 
which is inestimably more valuable to the surgeon than any 
theoretical knowledge of technic. 

The safe surgeon is he who has so accustomed himself to 
the technique of asepsis and antisepsis that he carries it out 
rigidly in an automatic manner and is thus free to concen- 
trate his entire attention on the surgical problems before 
him. 

The student who consults his interests will go yet farther 
and prior to undertaking any operation on the living subject 
will study the regional anatomy of the part on the cadaver 
and learn therefrom all that he can of the structure of the 
part which he must finally complete upon the living animal. 
No dissection of the cadaver can ever teach true surgical 
structure as the dead tissues can not be like the living, but 
such dissection can and does give great aid and should be 
pursued as far as it can lead and enough will still remain to 
be learned on the living subject. It is to be constantly re- 
membered that anatomy deals with the structure of the dead 
body while surgical operations are performed upon the 
livhig structures : they are not alike. 



xii INTRODUCTION. 

The student should further take occasion to study in con- 
nection with each operation the object or objects for which 
it is performed in practice, its effect on the diseased or other 
parts, the untoward results to be anticipated, etc. 

Suggestions occur from time to time in the text designed 
to aid the student in these lines and help weave connecting 
bonds between the operation, its objects and results. 

Surgical operations may in themselves be valueless or 
worse and acquire value only when properly correlated to 
disease and skillfully performed. 



Surgical and Obstetrical Operations. 



I. SURGICAL OPERATIONS. 



I. OPERATIONS ON THE HEAD. 
TOOTH OPERATIONS. 

Prefatory remarks. The grinding teeth of the horse 
consisting of three premolars and three molars in each row 
are of such dimensions and attachments that their removal 
in case of disease or defect often presents difficulties of no 
small degree. 

These teeth attain their greatest size at the time of erup- 
tion and most of each tooth remains firmly imbedded in its 
alveolus while a very shallow crown projects into the buccal 
cavity. The teeth are gradually pushed out of their alveoli 
as their crowns are worn away by attrition as age advances 
and the proportion of the intra- to the extra-alveolar part 
gradually decreases until in very old animals the alveoli be- 
come obliterated and the last vestige of what was once the 
apex of the fang rests insecurely in the buccal mucosa. 

The facility with which teeth may be extracted increases 
as the age of the animal, being as a rule easily drawn with 
forceps in old, while in case of freshly erupted teeth in 
young horses it may be almost or quite impossible to extract 
them with forceps of any kind, except in those cases where 
they have become somewhat loosened as the result of disease 
or accident. When aberrations in development occur, lead- 
ing to the formation of dental tumors or odontomes the 
possibility of extraction by means of forceps is frequently 
wholly excluded. In cases where dental disorder has led to 
empyema of the facial sinuses, even if the tooth may be 
drawn by means of forceps, further operation is generally 



2 EXTRACTION OF TEETH. 

necessary, in order to assure a prompt recovery, by the 
removal of the effects of the disease of the tooth. 

The removal of molars may therefore involve extraction 
with forceps, trephining the dental alveolus and repulsion 
of the tooth and trephining of the sinuses because of em- 
pyema or other pathologic conditions referable to the dental 
affection ; consequently all of these should be studied as 
related topics. 



1. EXTRACTION OF TEETH. 
Plates I and IL 

Instruments. Extracting forceps, fulcra of various 
sizes, mouth speculum with abundant lateral working room, 
exporteur forceps, toothpick, splinter forceps, reflecting 
lamp. 

Technic. In simple cases wdth a quiet animal the pa- 
tient may be sufficiently confined by being backed into a 
corner or very much better by securing in stocks. In com- 
plicated cases or very resistant animals it is best to place 
the patient upon the operating table or in default of this, 
cast and secure in lateral recumbence on the sound side. 

Apply the speculum and identify the diseased tooth by 
manual exploration ; determine if the tooth is of unnatural 
size or form, if it is loose, if the gums are separated from the 
neck at any point, if it is out of line with the other teeth in 
the row, if it is painful to the touch, if it be split, etc. An 
external tooth fistula or a tumefaction over the affected 
member may aid in distinguishing it. Aid may also be had 
by illuminating the mouth with a reflecting electric or other 
lamp. 

Remove any accumulations of partially masticated food 
by means of the toothpick or fingers. 

In applying the forceps, have an assistant draw the 
tongue out at the commissure of the lips on the side oppo- 

\' 



EXTRACTION OF TEETH. 3 

site to the aifected member and introducing one hand into 
the mouth, place the index finger on the posterior border 
of the diseased tooth and with the other hand, push the 
opened forceps backward upon the dental row until they 
reach the diseased member, then firml}^ grasp it with the 
instrument, pressing the jaws down as deeply as possible 
against the alveolus. 

In many cases the diseased tooth can be clearly seen, 
especially with the aid of the reflecting lamp, and the 
forceps may be readily applied by sight, which is frequently 
preferable to the sense of touch. 

Withdraw the free hand from the mouth, grasp the 
forceps handles firmly and loosen the tooth in its alveolus 
by establishing and maintaining as long as necessary a gentle 
to and fro lateral movement. The tooth is thus loosened in 
its alveolus by causing it to revolve very slightly back and 
forth on its long axis, thereby spreading the alveolar cavity. 
When the tooth has become well loosened, the fact is indi- 
cated by its revolving with the forceps and by an audible 
crepitant sound caused by the passage of air bubbles to and 
fro through the blood and lymph in the alveolus. Maintain 
the forceps in position with one hand and with the other 
introduce the fulcrum to a point where the depression on its 
superior surface will receive the projecting rivet-head of the 
instrument or in an otherwise secure position affording a 
safe support, while the inferior surface rests evenly upon 
the crown of a tooth anterior to that which it is desired to 
extract, as is shown in Plate I. The fulcrum needs be held 
firmly in place in order to prevent it from gliding away 
under pressure. 

In extracting the first premolars there is no opportunity 
for resting the fulcrum on teeth anterior thereto and con- 
sequently forceps have been made with fulcra beyond the 
forceps jaws resting upon teeth more posteriorly situated. 
This is not essential. If the tooth is thoroughly loosened, 



Plate I. 
Extraction of Teeth. 

Sagittal section through the oral cavity, show- 
ing plan for extracting the third inferior pre- 
molar, viewed from within the mouth. 

A Forceps jaws applied to third premolar. 

B Fulcrum resting upon first premolar. 

CC, Plates of mouth speculum resting upon 
incisor teeth. 



\ 

% 



EXTRACTION OF TEETH. 7 

as it should be, one hand placed in the interdental space 
with the dorsal surface against the jaw and the volar grasp- 
ing the instrument, will serve as an effective fulcrum. 

In other cases an iron or steel fulcrum is not essential, 
but a stick of hard wood of proper size and form acts quite 
as efficientl}^ and may even keep its position better because 
the teeth upon which it rests sink into it somewhat. On 
the whole the fulcrum is not so important as some have 
considered it, since, after a tooth is loose enough to be 
drawn with its aid, a very trifling additional loosening will 
permit it to be easily lifted from its alveolus without it. 

The tooth fang is extracted by forcing the handles of the 
forceps toward the jaw in which it is located, so that as it 
is gradually drawn out the forceps tend to pivot on the 
fulcrum in a way to permit the tooth to emerge from its 
alveolus in the direction of its long axis. By referring tO' 
Plate II it will be seen that the long axes of the different 
teeth vary, that of the molars being obliquely forwards from, 
fang to crown towards the incisors, while the crowns of the 
premolars are directed obliquely backwards toward the 
molars. The slant of the teeth is most marked at the ends- 
of each arcade while at the middle they acquire an almost- 
perpendicular position. 

In drawing the last molar the back of the forceps will, 
generally strike against the opposite dental arcade before 
the tooth has completely emerged from its alveolus and ini 
order to complete its removal it may be necessary to take- 
a deeper hold with the extracting forceps or withdrawing; 
these complete the operation with the aid of exporteur 
forceps, or stMl better frequently with the hand. In young 
horses where the teeth are very long we have found it im- 
possible to complete the extraction until the tooth had been 
divided transversely by means of the tooth cutting forceps. 

The dangers in the extraction of teeth are chiefly : 

I. The transverse fracture of the tooth, leaving the fang 
still fixed in the alveolus, a danger not infrequently un- 



B REPULSION OF TEETH. 

avoidable when the crown has become greatly weakened by 
disease so that it lacks the necessary power of resistance ; 
under most other conditions transverse fracture maj' be 
largel}^ guarded against by the careful securing of the 
patient in a manner to effectively prevent sudden throwing 
of the head while the forceps are applied, and by using good 
judgment in the amount of force exerted while loosening 
the tooth in its alveolus. As stated above we should not 
expect to be able to extract with forceps the teeth of very 
young horses which have not become partly detached by 
disease or in which the fangs are the seat of odontomes. 

2. Fracture of the alveolar walls is an accident which 
may generally be prevented by proper care in the application 
of force and the avoidance of any attempt to extract a tooth 
when the existence of an enlargement of the fang is apparent 
or suspected. 

3. The tooth may slip from the forceps into the pharynx 
and be swallowed, an accident avoidable by inserting the 
hand into the mouth as the tooth begins to emerge from its 
alveolus, and if need be, grasp it with the fingers. 



2. REPULSION OF TEETH. 
Plate II. 

Uses. The removal of molars, pre-molars, tooth fangs 
from which the crowns have been broken away, alveolar 
odontomes, etc., which can not be removed safely by means 
of the forceps. 

Instruments. Mouth speculum, razor, convex scalpels, 
trephine, bone gouge, Luer's sharp bone forceps, (rongeur 
forceps) light and heavy bone chisels, mallet, tooth punch, 
curette, compression artery forceps, scissors, needles, thread, 
absorbent cotton, antiseptic gauze, extracting forceps, 
splinter forceps, tenacula, metal probe. 



\ 



REPULSION OF TEETH. g 

Technic. Secure the animal in the lateral recumbent 
position with the affected side up. The operating table 
affords by far the best means for securing for the conven- 
ience and safety of operator and patient. If the sinuses are 
so involved as to make possible the inhalation of pus, blood 
or other injurious matter, perform tracheotomy in ample 
time to avert danger. Anaesthetize locally or generally as 
required. Shave and disinfect the operative area and 
trephine according to the method described in the following 
chapter, down through the alveolar plate immediately over 
the fang of the affected tooth. Avoid dulling the trephine 
by striking it against the tooth fang. 

If an external fistula exists the identity of the affected 
tooth is best determined by passing a metallic probe through 
it against the diseased fang while one hand is passed into 
the mouth and the location of the probe more fully ascer- 
tained. Care should be exercised in trephining to not injure 
the adjoining teeth. 

After removing the disc of bone isolated by the trephine, 
control all hemorrhage and then enlarge the opening and 
remove the bony tissues till the tooth fang is bared its entire 
width. Insert a scalpel or bone chisel between the external 
face of the bone and the soft tissues at the oral margin of 
the trephine opening and with one hand in the oral cavity 
with the fingers resting upon the alveolar border on the 
lateral side of the tooth to serve as a guide, push the scalpel 
or chisel along between the bone and soft tissues until it 
emerges from the gums alongside the affected tooth and 
extend this separation backwards and forwards until the 
soft tissues are completely detached from the alveolar wall 
over the entire area of the diseased member. 

When operating upon the superior molars, the fangs of 
which are covered by the zygomatic ridge, the chisel or 
scapel cannot be pushed directly from the trephine opening 
into the mouth between the soft tissues and the bone because 
the line is concave instead of direct. In these cases it is 



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REPULSION OF TEETH. 13 

best to detach the soft parts from the zygoma only at first 
and then remove the alveolar plate of the ridge with the 
bone forceps or chisel, after which the line into the mouth 
is direct and the instrument can then be readily pushed be- 
tween the soft and osseous tissues for the remainder of the 
distance and the separation completed. 

In operating upon the inferior molars covered by the 
masseter an opening through the muscle may be made near 
its lower border large enough to admit the trephine or the 
muscle may be detached at its point of insertion to the 
inferior maxillary bone and two parallel incisions carried 
upwards a short distance, permitting the raising of a flap, 
or what is generally best for the second and third molars, a 
curved incision is made at the antero-inferior border of the 
masseter muscle parallel to the parotid duct and satellite 
vessels and just posterior to them and the muscle lifted up 
and drawn backwards sufficiently to expose the bone im- 
mediatel}^ over the tooth fang. 

With a light, narrow bone chisel cut away and remove 
the external alveolar plate over the entire extent of the 
tooth, from the oral margin of the trephine opening inta 
the mouth cavit}^ Hold the chisel so that the outer edge is 
inclined from the affected tooth toward the adjoining one, 
thus making a bevelled channel through the alveolar plate 
tending to loosen the isolated section of bone by driving it 
outwards. Drive the chisel for a short distance on one 
side, then upon the other, and thus break the alveolar plate 
away in small sections and avoid an extension of the 
fracture to neighboring alveoli and damage to adjacent 
teeth. Care should be taken that the bone chisel is sharp 
otherwise extensive fractures of the bone may occur. With 
gouge and chisel remove all remnants of bone over the 
lateral side of the tooth laying it completely bare as shown 
in Plate II. 

The soft tfssues of the part should not be disturbed 
beyond the excision of the circular piece, corresponding to- 



14 REPULSION OF TEETH. 

the disk of bone removed by the trephine and the detaching 
of them from the portion of bone to be chiseled away. 

When the tooth has been bared so that every part of its 
lateral surface can be seen or felt, the punch may be placed 
against the end of the fang, a few firm, quick blows given 
with the mallet, so directed that the force is in a line with 
the long axis of the tooth, and the organ driven into the 
mouth where it is seized by the forceps or the hand and 
removed. If it is not readily and safely dislodged in this 
waj' , place the heavy bone chisel against it and wath the aid 
of the mallet comminute the tooth b}^ breaking it trans- 
versely and splitting it longitudinally, in which process the 
fragments are generally loosened from the alveolar walls and 
can then be readily removed with the aid of the gouge, or 
heavy dressing or splinter forceps. Remove carefully all 
fragments of tooth or of loosened bone, cleanse and disinfect 
the wound, pack with iodoform gauze and dress daily. 

In cases where a fistulous opening remains after repulsion 
of molars without the removal of the alveolar wall, or if a 
tooth has been drawn by means of the forceps and the 
alveolus fails to heal, the bon}' plate should be removed in 
the above manner. 

Dangers. Wounding of the adjoining tooth is to be 
avoided chiefly by carefully locating the fang of the affected 
one and placing the instrument as exactly as possible over 
its centre, b}^ using a trephine not exceeding 2 to 2.5 cm. in 
diameter and cautiously sawing through the compact layer 
of the external plate only, removing the cancellated tissue 
with the gouge and extending the opening in the desired 
•direction after the outlines of the tooth fang have been 
clearly determined. If an adjoining fang is wounded, the 
tooth should be removed as it will not heal but will result 
in a permanent tooth fistula. 

Fracture of the alveolar walls of the inferior maxilla 
may occur during the removal of the external alveolar plate 
with the chisel or of the repulsion of the tooth with the 

\ 



REPULSION OF TEETH. 1 5 

punch. The first is to be averted by care in having the 
chisel sharp, b}^ observing the precaution of making a 
bevelled cut through the bone, by using only moderate 
blows and driving the instrument alternately for a short 
distance on each side. The second danger of extensive 
fracture may be averted by being cautious to see after each 
stroke on the punch that it has not slipped inward along 
the median side of the tooth, pressing the internal plate 
away from the tooth and tending to produce a longitudinal 
fracture nearly or quite as long as the dental arcade. 
Careful digital exploration in the mouth may discover this 
fracture while still "simple" but a stroke or two more will 
convert it into the very much more serious ' ' compound ' ' 
fracture opening into the oral cavity. Keeping one hand 
constantly in the mouth at the point of impact is always 
desirable as a precautionary measure. 

Transverse fracture of the tooth while yet in situ by 
means of the bone chisel, as above described, is a great safe- 
guard against this injury by lessening the force required in 
repulsion and by the removal of the tapering fang, which 
then leaves a more secure base for the punch to act upon. 
It should never be forgotten that the impact from the punch 
must always be as nearly parallel to the long axis of the 
tooth as is possible. 

The fracture of the superior maxilla and bony palate is 
not so probable as the preceding and is preventable by mod- 
erate care in the denuding of the tooth before punching, by 
comminution of the tooth in proper cases, by the careful ad- 
justment of the punch and applying the force in the proper 
direction. 

Literature. Odontomes, Sir Bland Sutton, Jour. Comp. 
Med. and Vet. Arch, Vol. XII. p. i ; A Clinical Study of 
Odontomes, W. ly. Williams, Am. Vet. Review, Vol. XV, 
p. I ; Notes on Odontomes, do ; Am. Vet. Rev. Vol. XXIII, 
p. 82 and Oest. Mon. Thierheilkunde, Bd. XXIV, s. 122. 



1 6 TREPHINING OF THE FACIAL SINUSES. 

TREPHINING OF THE FACIAL SINUSES. 
Plates III- XL 

Prefatory Note. The facial sinuses of the horse consti- 
tute an exceedingly intricate and extensive group of cavities, 
communicating more or less freely with each other or with 
the exterior through the medium of the upper air passages, 
of which they are to be regarded as a part. 

Their arrangement and relations permit them to frequently 
become the seat of, or central figure in many forms of disease 
which require for their differential diagnosis, amelioration 
or cure, the operation known as trephining. Their extent 
and relations to each other and to surrounding parts varies 
greatly with age and may be profoundly changed as a result 
of disease, amounting not infrequently in the frontal, 
superior and inferior maxillary sinuses ceasing to exist as 
separate cavities and becoming merged into one vast diverti- 
culum. The general position, extent and relations of these 
are indicated by Plates III-XI. 

It is to be noted that in cross sections the superior and 
inferior maxillary sinuses appear to be reversed in relation, 
to their nomenclature. It is difficult to make a cross sec- 
tion of these sinuses in such a manner that the antero- 
inferior extremity of the superior sinus does not show below 
and external to the inferior one. The inferior maxillary 
sinus is inferior in the sense that it is nearer to the nasal 
opening so that with the head in a vertical position or in a 
longitudinal section the inferior sinus is below the superior, 
while if the head be placed horizontally or a cross section 
made, a small portion of the superior sinus may show below 
the inferior. 

The uses of trephining are in a measure common to all 
the sinuses and are chiefly for the relief of empyema of the 
cavities involved, necrosis of the bony or cartilaginous walls, 
tumors of various kinds, especially dental in the young and 

\ 

% 



TREPHINING OF THE FACIAL SINUSES. ly 

malignant growths in the old, foreign bodies in the sinuses, 
differential diagnosis of diseases of this region, etc. 

Veterinarians trephine the sinuses b}^ two fundamentally 
different plans ; with, and without excision of the cutaneous 
disk corresponding to the piece of the bone removed. The 
first is generally' used in Great Britain and North America, 
while the last is the prevailing method in continental 
Europe and other parts of the world. The reason assigned 
for these variations in method are conflicting. To us there 
seem to be adequate reasons for preferring the excision of 
the cutaneous disk. We regard as the chief considerations 
in an operation the following : the avoidance of infection ; 
the prevention of pain during the operation or the after- 
treatment ; the reduction of the scar to a minimum ; rapidity 
and certainty of recovery ; convenience in operating and 
dressing. Inevitably a septic operation, the degree of 
infection is largely dependent upon the area of the wound, 
the facility for maintaining cleaniness and the degree of 
disturbance to the tissues while being dressed. The wound 
area in the bone is alike in all cases but that in the skin 
varies greath\ If we compare the usual European technic 
with that given below we would find the wound area ap- 
proximately 2.2 sq. in. in the European method, while in 
the latter we have only about .44 sq. in. or proportionately 
the wound area in the soft tissues in the two operations 
would be as 5 : I . 

It is very evident that the technic given below affords 
immeasureably better facility for maintaining cleanliness in 
the wound and with a minimum amount of insult to the 
tissues in the process of dressing. 

The amount of pain caused in the operation which should 
be eliminated by local anaethesia depends chiefly upon the 
extent of the skin incision which is essentially equal in the 
two plans so that the only difference would be in the 



1 8 TREPHINING OF THE FACIAL SINUSES. 

dissection of the skin from the bone in the European 
operation. The pain caused in dressing must be greater in 
the European method because the detached, overhanging 
skin must be moved and disturbed each time causing pain 
and inviting infection. The question of pain in dressing 
must alwa3^s be seriously considered as it not only affects 
the time required for dressing and its efhcacy, but has an 
important relation to the docihty of the animal after re- 
covery, some horses having their dispositions permanently 
ruined by the irritation due to the oft repeated painful 
dressing of wounds. 

The cicatricial contraction of the tissues of the horse is 
so great that the removal of a circular disk of skin y%\.o i^z 
in. in diameter on the face does not leave a visible scar 
so that the question of blemish falls back upon that of 
infection, which, as we have asserted above is far more 
probable by the continental European method. 

The rapidity and certainty of recovery are dependent 
upon the considerations above discussed. The removal of 
the cutaneous disk is certainly easier and quicker than the 
other method. The convenience for dressing is evidently 
superior by the English and American method. 

The opening of the sinuses into the nostrils is based upon 
the surgical principle that suppurating cavities should be 
provided with ample drainage from the most dependent 
part. The direction to leave the external wound open, at 
first thought seems antagonistic to general surgical princi- 
ples but it should be remembered that the wound consists 
only of the incision through the skin, connective tissue 
and bone penetrating a suppurating cavity, and that any 
object which we can place in this opening can only serve 
to dam back the secretions of the cavity and can not prevent 
them from coming in contact with the wounded surface. 
It must further be regarded that the respiratory mucosa of 
the upper air passages are not irritated or injured in any 



\ 
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TREPHINING OF THE FRONTAL SINUSES. 19 

manner so far as we can observe clinically by the direct ad- 
mission of air into them through a trephine, or other artificial 
opening, but on the contrary the suppuration in a sinus is 
constantly aggravated by the retention of the pus and ex- 
clusion of air and recovery facilitated by thorough drainage 
and aeration. 



3. TREPHINING OF THE FRONTAL SINUSES. 
Plates Ill-XL 

Uses. Fracture of the bony walls, necrosis, tumors. 

The ample communication below with the superior 
maxillary sinus (See FE, Plates V and VI) prevents the 
accumulation of pus or fluids in the frontal sinuses even if 
formed therein unless the former becomes filled and the 
contents back up into the latter. In empyema of the 
frontal sinuses, trephining can not give relief, but calls for a 
repetition of the operation on the maxillary sinuses. 

Instruments. Razor, scissors, convex scalpels, artery 
forceps, tenacula, probe, trephine, curette, gouge, Luer's 
sharp bone forceps (rongeur forceps), hammer, chisel, 
probe-pointed bistoury, dressing forceps, disinfecting and 
dressing materials. 

Technic. The operation may be performed upon the 
standing animal with the aid of local anaesthesia of the 
skin, the bone having virtually no sensation. Restless 
animals may be further secured with the twitch, in the 
stocks, upon th,e operating table or b}^ casting on the sound 
side. 

Clip and shave the hair from the region of the frontal 
bone at that point which the operator has reason to beheve 
is nearest the center of disease. The highest point at which 
the sinus may be trephined is indicated by F in Plate III. 
The most central portion of the cavity is reached by trephin- 



Plate III. 
Trephining the Facial Sinuses. 

F, highest point at which an opening may be 
made into the frontal sinus without wounding 
the cranium and brain ; N. opening into naj^al 
sinus ; SM, opening into superior maxillary 
sinus ; IM, opening into external portion of in- 
ferior maxillary sinus ; IM^ opening into the 
median portion of the inferior maxillary sinus. 



\ 




5M 



IM 



^ IM 



TREPHINING OF THE FRONTAL SINUSES. 23 

in^ on a level with the inferior border of the orbital cavity 
on the lines FE, Plates V and VI. Trephining at this 
point gives the operator access to the superior maxillary 
sinus, SM, Plates IV-VI, through the fenestrum, FE, 
Plates V and VI. The lowest and generally most essential 
point for trephining is at ST, Plates IV and V, where the 
opening affords free drainage externally from the most de- 
pendent part of the cavity and at the same time offers 
ample opportunity for securing dependent nasal drainage by 
breaking through the superior turbinated bone at ST, 
Plates IV, V and XI. 

By consulting Plates VII-IX, it will be seen that after 
reaching the level of the nasal septum, a trephine opening 
immediately against the median line like that at F, Plate 
III would wound the septum and superior turbinated bone 
and penetrate the nasal cavit3\ Consequently the operator 
must avoid making the trephine opening in this region near 
the median line, but must keep 1 34 to 2 inches laterally 
therefrom. 

With a heavy convex scalpel make a circular incision at 
the desired point as large as the area of the trephine, directly 
through the skin, subcutem and periosteum down to the 
bone and remove in one piece the entire mass of encircled 
soft tissues by seizing the skin with a tenaculum and forcibly 
separating the periosteum from the bone with the scalpel or 
bone chisel. Control the hemorrhage. 

With the center-bit of the trephine extended place it accu- 
rately upon the denuded area perpendicular to the surface 
of the bone and grasping the handle firmly turn it to and 
fro until the bit has penetrated the bony plate and the saw 
has cut a distinct groove to serve as a guide when the center- 
bit should be retracted and the operation continued until 
the disc of bone is detached, being careful to maintain the 
trephine perpendicular to the surface. The operation is 
facilitated by. grasping the shaft of the trephine between 



Plate IV. 

Trephining of Facial Sinuses. 

Right side of face, viewed laterally, showing extent and 
relations of the sinuses. O, orbital cavity ; SM, superior 
maxillary sinus ; IM^, median portion of inferior maxillary 
sinus ; NC, nerve conduit of superior maxillary trunk of the 
trifacial ; IM, lateral portion of inferior maxillary sinus ; F, 
frontal sinus ; vST, opening through superior turbinated bone 
for the establishment of drainage from the frontal and superior 
maxillar}' sinuses into the nasal passage ; IT, opening through 
inferior turbinated bone for the establishment of drainage 
from the median portion of the inferior maxillary sinus into 
the nasal cavitv. 



\ 
% 



TREPHINING OF THE FRONTAL SINUSES. 27 

the thumb and fingers of one hand, constituting a support 
in which it may turn back and forth. The pressure under 
which the trephining is carried out must not be too great 
or the instrument may become wedged and broken. 

When the bony plate which has been isolated begins to 
loosen, remove the trephine and break, or pry out the piece 
of bone with the bone gouge or chisel. Smooth an}^ uneven 
edges of bone with a heavy scalpel or by re-inserting 
the trephine and using it as a rasp. The abnormal contents 
of the sinus may now escape through the opening or be re- 
moved with the curette, forceps or scissors, and the cavity 
irrigated with an antiseptic fluid. 

Leave the trephine wound entirely open and irrigate the 
sinuses dail}^ with antiseptics. 

The frontal, being in free communication below wnth the 
superior maxillary sinus, the irrigating fluids may fall 
directly into the latter until it becomes filled. The superior 
turbinated bone of the same side forming the median wall 
of the frontal sinus, it is commonly perforated by necrosis, 
in cases of serious disease establishing a communication be- 
tween the frontal and nasal cavities, through which pus 
and irrigating fluids readily escape into the nostril. 

It has been assumed that pus or other contents in con- 
siderable quantity might pass from the superior maxillary 
sinus into the nasal cavity through the normal communi- 
cating slit between the two cavities but a careful study of 
anatomical arrangement of these parts, opposite N, Plates 
VII-X, shows very clearly that it is impossible as the 
margins of the slit acts as a valve and closes it when pressure 
is applied from within. 

In order to prevent the aspiration by the patient of the 
contents of the sinuses, whether pus, blood or irrigating 
fluids, and to facilitate their escape from the nostril, any 
irrigation on the recumbent animal should be carried out 
with the poll elevated and the head flexed. 



Plate V. 

Trephining of Facial Sinuses. 

Oblique lateral view of the face with the sinuses exposed. 
SM, superior maxillary sinus ; IM^, median portion of in- 
ferior maxillary sinus ; NC, nerve conduit of superior maxil- 
lary division of trifacial nerve ; IM, lateral portion of inferior 
maxillary sinus ; F, frontal sinus ; FE, fenestrum of com- 
munication between the frontal and superior maxillar}' 
sinuses ; ST, artificial opening through the superior turbi- 
nated bone at the lowest part of the frontal sinus establishing 
a free communication with the nasal passage ; IT, artificial 
opening through the inferior turbinated bone at the bottom 
of the median portion of the inferior maxillary sinus, affording 
drainage into the nasal passage. 



\ 

% 



TREPHINING OF THE FRONTAL SINUSES. 31 

By studying Plates IV-X it will be seen that any collec- 
tion of pus or other pathologic contents in the frontal sinus 
at F would result in poor drainage so far as may be obtained 
by trephining through the external wall only. The 
drainage, whether the contents have formed within the 
frontal sinus itself, or have entered it through the fenestrum, 
FE, Plates V and VI, from the superior maxillary sinuses 
should be completed by making an artificial communication 
through the turbinated bone between the frontal sinus and 
the nasal fossa at ST, Plates IV, V and XI. This is to be 
accomplished by breaking through the thin walls of the 
turbinated bone by means of a probe or other suitable instru- 
ment and enlarging the opening sufficiently with the probe- 
pointed bistoury or with the finger. In locating the exact 
point for making this opening in the turbinated bone it is 
advisable to pass a slightly curved heavy probe, a pair of 
long curved uterine dressing forceps or some other slightly 
curved and somewhat rigid instrument up the nostril to 
the operative region and having an index finger in the 
sinus against the median wall, the movements of the sound 
can easily be felt and the wall be broken down either by 
pushing the sound up into the sinus or thrusting the finger 
downwards into the nasal passage. 

In order to prevent aspiration of pus, blood or other fluids 
after the perforation of the highly vascular turbinated bone, 
the animal must be allowed to get up immediately or if 
under general anaesthesia a trachea tube should be inserted 
sufiiciently early to avoid danger. 

Thread a long probe with a heavy suture about 75 cm. 
long and inserting it through the trephine opening into the 
nasal passage draw it out through the nostril and removing 
the probe, attach a strip of gauze 75 cm. long to one end of 
the suture, draw it out through the nostril and tie the ends 
together on the side of the face to prevent dislodgement. 
Retain the gauze in position for about forty-eight hours to 



32 



TREPHINING SI 'PER 10 R MAXILLIAR Y SINUSES. 



insure the permanency of the opening through the turbi- 
nated bone. In case of severe hemorrhage the nasal and 
sinusal cavities may be tamponed for twenty-four hours with 
a long strip of gauze which may be secured if necessary by 
suturing to the lips of the trephine wound. In practice the 
operation can be best carried out generally with the animal 
in the standing position the operative area being first 
anaesthetized by the use of cocaine or by inducing artificial 
oedema. In the standing position we largely avoid the 
danger of aspiration of fluids and the hemorrhage is greatly- 
lessened. 



4. TREPHINING THE SUPERIOR MAXILLARY SINUSES. 
Plates lll-X. 

Uses. Empyema, diseased teeth, odontomes or other 
tumors. 

Instruments. Same as for the frontal sinuses. 

x\natomically there are two maxillary sinuses, superior, 
SM, and inferior, IM, Plates III-X, having a thin im- 
perforate bony partition between them. This partition, 
shifts somewhat in position with age and in case of disease 
undergoes profound changes in location and is frequently 
totally obliterated in cases of empyema, dental cysts and 
other affections. If the sinusal partition be present, good 
drainage of the superior sinus may demand the surgical 
destruction of the partition so that some authors advise 
trephining directly upon the partition in ordei to open the 
two cavities simultaneously. 

In extensive disease of either sinus the partition between 
the two frequently becomes obliterated so that there remains 
but one sinus to open ; in limited disease the opening of both 
cavities is ill advised. In extensive disease the existence 
of a partition may generally be ignored in operating and 



TREPHINING SUPERIOR ^[AXILLARY SINUSES. 33 

the trephine opening be aimed at the probable focus of the 
malady and, should this fail to reach the desired locality, 
the proper location for the opening may now be determined 
by digital or other examination through the first opening. 
A second operation should then be made to directly reach 
the seat of the affection and if need be, yet a third to secure 
proper drainage. 

Shave and disinfect as much of the area as may be re- 
quired bounded above by the inferior border of the orbital 
cavity, laterally by the zygomatic ridge, inferiorly by the 
lower end of the zygoma and medianwards by the middle 
line of the face. Determine the proper point for operation 
by percussion or otherwise. If it be desired to enter the 
superior maxillary sinus only, SM, Plates III-X, locate the 
opening beneath the orbital cavity and in front of the zygo- 
matic ridge, SM, Plate III, or at any point directly beneath 
this to midway between SM and IM, Plate III, at about 
the level of the dotted line IM'. 

The trephining is carried out as described for the frontal 
sinuses on page 19. After the trephining has been com- 
pleted remove any purulent collection or tumors or carry 
out an}' other necessary operation in the affected sinuses 
and after cleansing, if the trephine opening does not insure 
perfect drainage of the lateral sac, either lower it by cutting 
away its inferior border with the bone forceps or make a 
second trephine opening at the necessary point. 

Since empyema of the superior maxillary sinuses is due in 
the vast majority of cases to infection derived from diseased 
teeth or dental alveoli it is essential after the sinus has been 
opened that the operator search carefully and minutely over 
the alveoli of the molars for naked, eroded tooth fangs or 
for fistulae leading down into the dental alveoli. If dental 
disease is recognized the trephining of the sinus is to be 
supplemented by repulsion of the offending tooth as 
described on page 8. 
3 



Plate VI. 

Trephining of Facial Sinuses. 

Frontal view of right side of face with sinuses 
exposed. SM, superior maxillary sinus ; IM', 
median portion of inferior maxillary sinus ; IM, 
lateral portion of inferior maxillary sinus ; F, 
frontal sinus ; FE, communication between the 
frontal and superior maxillary sinuses. 



SH 




TREPHINING SUPERIOR MAXILLAR Y SINUSES. 37 

Under the influence of disease the sinuses ma}^ extend far 
beyond their normal location or ma}- contract or become 
largely obliterated by being filled with new bone or soft 
tissue. The median portion of the superior maxillary sinus 
on the inner side of the bony conduit of the trifacial nerve, 
NF, Plates IV-X, can not always be completel}^ drained 
through the opening SM, Plate III, and provision for this 
must then be made by trephining into the lower part of the 
frontal sinus and thence breaking through the superior 
turbinated bone, ST, Plates IV-V, into the nasal passage 
or at times it may be feasible to break through the inner 
wall of the superior maxillary sinus on the median side of 
the nerve conduit into the nasal cavity. If the inferior 
maxillary sinus is also involved good nasal drainage 
may be had by breaking down the inter-sinusal partition 
and then penetrating the inferior turbinated bone at IT, 
Plates IV-V, and inserting through this opening a long and 
thick strip of gauze which is brought out through the nostril 
and the ends tied together on the side of the face to prevent 
displacement. Retain this in position, renewing daily until 
the permanency of the opening is assured. 

It generally occurs in extensive empyema of the sinuses 
that an opening in the turbinated bone takes place b}^ 
necrosis and in some cases affords the desired drainage 
while in the majority the pathologic opening is so placed 
that it is incomplete. 

Leave all wounds entirel}' open and irrigate daily with 
antiseptic solutions. 

Dangers. Care must be exercised to not injure the 
superior maxillary division of the trifacial nerve, NF, 
Plates IV-X, either in trephining or after the sinuses have 
been opened. The bony conduit of this nerve is in rare 
cases entirely resorbed by pressure from dental cysts or 
other causes, leaving it stretched across the cavity as a white 
nacrous cord, intensely sensitive. Any injury to this nerve 



Plate VII. 

Trephining of Facial Sinuses. 

Cross section of the right half of the head of 
a horse at the posterior border of the last molar. 
F, frontal sinus ; IM, lateral portion of inferior 
maxillary sinus at extreme posterior or superior 
part ; IM^, median portion do.; N, nasal cham- 
ber opposite the communication between it and 
the superior maxillary sinus ; NF, conduit of 
superior maxillary branch of the trifacial nerve ; 
SM, superior maxillary sinus ; M^, fragment of 
last molar. 




V-__^ 



TREPHINING INFERIOR MAXILLAR Y SINUS. 41 

causes intense pain and renders the animal very resistant to 
the necessary manipulations in the after care of the wound 
and may leave the patient pernamently nervous about the 
handling of its face. 

Hemorrhage is generally not severe and may occur from 
the skin, where it may be readily controlled by compression 
or ligation ; from the intra-osseous vessels, where it may 
be checked by pressure with absorbent cotton, by pushing 
a small portion of cotton into the channel of the vessel 
with a needle or tenaculum or by plugging the vessel with 
a conical piece of wood ; from the wounded turbinated 
bones where it may be stopped by packing with gauze. 
These tampons should be removed after twenty- four hours. 



5. TREPHINING THE INFERIOR MAXILLARY SINUS. 
Plates Ill-XL 

Uses and Instruments. Same as in the preceding. 

Anatomical Outline. The inferior maxillary sinus is 
an exceedingly irregular cavity, differing in details of form 
and extent in individuals and at various ages. As shown 
in the illustrations its disposition might be compared to a 
pair of saddle bags hanging over the nerve conduit, the 
lateral and median chambers not very unlike in extent. 
As suggested in Plates IV-V, the floor of the lateral cavity 
is broken up by irregular bony septa, which in some cases 
cut the sinus up into quite separate cavities. Sometimes it 
extends downwards barely below the end of the zygoma, 
at other times- it reached down below the infra-orbital 
foramen. There is hence no rule by which the operator 
may at all times make his opening precisely at the lower 
extremity of the sinus. 

Technic. The general technic is the same as for the 
frontal and superior maxillary sinuses, but two trephine 



Plate VIII. 

Trephining the Facial Sinuses. 

Cross section of the left side of the head of an 
aged horse at the second molar, seen from the 
front. F, frontal sinus ; N, nasal sinus, oppo- 
site the communication between the nasal and 
inferior maxillary sinuses ; IM, lateral portion 
of inferior maxillary sinus ; IM^, median portion 
of inferior maxillary sinus ; SM, superior max- 
illary sinus ; NF, superior maxillary division of 
trifacial nerve in its bony conduit ; SZ, subzygo- 
matic artery ; P, palatine artery ; M2, second 
molar. 



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TREPHINIFG THE NASAL FOSSAE. 45 

opeuings should always be made. The first opening should 
be made close against the median side of the zygoma near 
its lower or nasal extremity, Plate III, IM, and the inferior 
border lowered sufficiently with the bone forceps to provide 
thorough drainage for the lateral compartment of the sinus. 
The second opening is to be made on the median side of 
the nerve conduit, NC, Plates IV-V as indicated at IM' in 
Plate III. The location may he accurately determined by 
palpating with the index finger through the first opening 
at IM, Plate III. This compartment can not be well drained 
upon the face through either of the trephine openings and 
a third opening, penetrating the inferior turbinated bone at 
IT, Plates IV-V, is essential to ideal results by affording 
free drainage into the nasal chamber. The opening through 
the inferior turbine is made in the same manner as described 
for the opening through the superior turbine from the 
frontal. Thorough search should be made throughout the 
sinus for the causes of disease, teeth, etc., these removed and 
followed by after treatment the same as advised for the two 
preceding operations. 



6. TREPHINING THE NASAL FOSSAE. 
Plates Vll-X. 

Uses. Operations upon the septum nasi, or the tur- 
binated bones, or the removal of tumors or foreign bodies 
from the nasal passages. 

Instruments. Same as for the frontal sinuses (page 

19). 

Technic. The trephining, N, Plate III, is carried out 
by the method described above, in the nasal bone, close by 
the median line of the face and according to indications at 
any point from a level of the dotted line, SM, Plate III, to 
the juncture between the nasal and pre-maxillary bones 
near the upper extremity of the false nostril. 



Plate IX. 

Trephining the Facial Sinuses. 

Cross section obliquely downwards and back- 
wards through the right half of the head of a 
two-year old colt at the first molar. F, frontal 
sinus ; N, nasal passage at point of communica- 
tion with the inferior maxillary sinus, IM ; IM^, 
median portion of inferior maxillary sinus ; SM, 
extreme lower end of superior maxillary sinus 
opened; Mi, first molar; M2, second molar; 
P, palatine artery ; SZ, sub-zygomatic artery. 







— r--Ml 



' Ma 



TREPHINING THE NASAL FOSSAE. 49 

A study of Plates VII-X will show that the trephining 
of these cavities requires great care in order to avoid wound- 
ing either the highly vascular septum nasi or even more 
vascular turbinated bones. The operation should be im- 
mediately against the septum since otherwise the superior 
turbinated bone may be wounded or an important intra- 
osseous artery in the nasal bone, just above its union with 
the superior turbinated, as shown in Plate IX, may be 
severed. 

If the turbinated bone is penetrated the frontal, and 
through it, the superior maxillary sinus is opened and ex- 
posed to infection with all its consequences. Special care 
is accordingly necessary that the trephining should not be 
carried too deeply, that the bone be barely penetrated, and 
that the osseous disc be carefully removed in order to avoid 
the wounding of the turbinated bone, which lies in close 
proximity to the nasal bone. The operative area is narrow 
and the trephine used should not exceed 2 cm. in diameter. 

Whenever possible the operation should be carried out 
on the standing animal which decreases the hemorrhage 
and the danger from aspiration of fluids. The hemorrhage 
may be further controlled in operations upon the septum 
nasi and turbinated bones by spraying the parts with 
adrenaline chloride and cocaine. Even in the standing 
animal, if extensive operations are to be carried out on the 
very vascular .septum nasi or on the turbine, it is advisable 
to preform trachetomy before trephining, and retain the 
trachea tube in position until all danger has pa.ssed. When 
the animal is confined in the recumbent position the 
patient's safety'demands that tracheotomy be performed in 
almost all cases before any operation is begun upon the 
septum nasi or turbinated bones. After tracheotomy, 
anaesthesia ma}^ be maintained by means of an ordinary 
funnel with its tube bent at right angles and inserted into 



Plate X, 

Trephining of Facial Sinuses. 

Cross section of the left side of the head 
anterior to the last molar, and through the 
widest part of the inferior maxillary sinus. M', 
last superior molar ; SM, superior maxillary 
sinus at its antero-inferior extremity ; IM, in- 
ferior maxillary sinus, lateral portion ; IM^, do. 
median portion ; N, nasal fossa ; S, sound 
lodged in lachrymal duct ; NF, trifacial nerve ; 
F, frontal sinus. 




^_.__SM 



r — M 



POLL EVLL OPERATION. 53 

the trachea tube while the chloroform is dropped on a towel 
spread over its mouth. After completing any required 
operation upon the septum, turbinated bones or other parts, 
hemorrhage may be controlled by packing one or both nasal 
fossae with single strips of gauze of sufficient size and 
carefully securing them by sutures to the sides of the 
trephine wound or otherwise. 



7. POLL EVIL OPERATION. 
Plate XI. 

Instruments . Clipping shears, razor, sharp scalpels, one 
dozen compression artery forceps, probe-pointed bistoury, 
probe, IvUer's bone forceps, bone gouge, curette, suture and 
dressing material. 

Technic. Clip the foretop and mane and shave the 
forehead and the top of the neck back to a distance of 8 or 
10 cm. or as much farther as may be required to pass beyond 
and behind the supposed extension of disease, and disinfect 
the area. Confine the animal in lateral decubitis preferably 
upon the operating table, place under complete anaesthesia 
and remove the halter or other headgear. 

With sharp scalpel make a longitudinal incision on the 
median line of the head and neck beginning at a point 
presumably posterior to the diseased area and carrying it 
over the poll down onto the forehead for a distance of 4 or 
5 cm. below the foretop. Continue this incision through 
the skin, the subcutem, the adipose tissue, AT, Plate XI, 
and either through, or passing around alongside the neck 
ligament, LN, into the diseased area beneath the latter. 
Dissect the ligamentum nuchse away from the adjoining 
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POLL EVIL OPERATION. 57 

portion of the ligament in the area indicated and all calca- 
reous deposits or other diseased tissues. 

With lyUer's forceps groove a channel about 2 cm. wide 
from behind to before directly upon the median line, through 
the occipital protuberance to the depth of about 2 cm. mak- 
ing the bottom as near as possible on a level with the wound 
in the soft tissues as indicated by the dotted line, AA. 
Using Luer's forceps as a curette detach all vestiges of the 
neck ligament from the base of the occiput and leave the 
bone bare and smooth. If the Luer or ronguer forceps are 
not available the grooving of the occiput ma}^ be accom- 
plished with a strong curved bone gouge. Or the grooving 
of the occiput and curetting away of the attachments of the 
neck ligament to the base of the occiput may be very 
effectually accomplished with a hoof knife. Be careful to 
avoid penetrating the cranial cavity or the occipito-atloid 
articidatio7i . If the operator is not perfectly clear regarding 
the anatomy of the parts he would do well to have before 
him a sagittal section of the head of a horse which may 
serve as a guide. In curetting the ligamentous attachments 
from the occiput the operator should keep the index finger 
of the left hand at the bottom of the wound, against the 
occipito-atloid ligament in order to protect it from injury. 
The operation is rendered safer also by rigid control of the 
hemorrhage to which end he needs an ample number of 
compression artery forceps. 

Control the hemorrhage, cleanse and disinfect the wound, 
pack with iodoform gauze and suture for its entire length 
except the anterior part, where the tampon should slightly 
protrude, and dust the margin of the wound with iodoform 
and tannin. Remove the tampon after forty-eight hours 
and dress antiseptically daily. The sutures may or may 
not be removed according to conditions. In carrying out 
this operation our chief aim should be to remove all diseased 
parts, to afford perfect drainage anteriorly, to secure and 
maintain antisepsis, and to keep the wound directly on the 
median line from which no visible scar will result. 



Plate XII. 
Ligation of the Parotid Duct. 

Fig. I. Segment of the left ramus of the in- 
ferior maxilla of the horse seen from the right 
and beneath, sp, usual operative field ; a, ex- 
ternal maxillary artery ; v, external maxillary 
vein ; st, st, parotid duct. 

Fig. 2. Life size of operation field on external 
side of maxilla ; a, external maxillary artery ; i\ 
external maxillary vein ; st, parotid duct ; i)i^ 
masseter muscle. 




Fig. I, 




Fig. 2. 



LIGATION OF THE PAROTID DUCT. 6 1 

8. LIGATION OF THE PAROTID DUCT. 
Plate XII. 

Objects. The destruction of the parotid gland in case of 
fistula from wounds or abscesses. 

Instruments. Razor, convex scalpel, straight probe- 
pointed scalpel, tenaculum forceps, ligation forceps, tenacula, 
needle holder, probe, suture and dressing material. 

Technic. In case of salivar}^ fistula insert a probe 
toward the gland through the fistula into the duct and with 
a sharp scalpel lay the duct free for a distance of from i to 
2 cm. on the glandular side of the fistulous opening. If the 
fistula has its location on the side of the cheek, cast the 
horse and shave and disinfect the region on the inferior 
maxilla where the arter3^ vein and parotid duct turn around 
its inferior border. When the operator glides his finger 
over the vascular region forward and backward there is felt 
a resistant cord, the pulsating external maxillary artery 
about 3 mm. in diameter. Between this and the oral border 
of the masseter muscle make an incision about 4 cm. long 
parallel to the artery through the skin and skin muscle. 
Pick up the loose connective tissue with a pair of forceps 
and excise it. Immediately behind the external maxillary 
artery, a, Figs, i and 2, Plate XII, is the external maxil- 
lary vein, V, and behind this and immediately at the border 
of the masseter muscle lies the parotid duct, st. 

In case of salivary calculi which cannot be removed 
through the mouth or of cystic dilation of the parotid duct, 
make the cutaneous incision at the affected point, open the 
canal, and after the removal of the calculus, etc., close the 
duct wound by means of intestinal sutures in such a way 
that the external surfaces of the lips of the wound in the 
wall of the duct are brought in contact, or ligate the duct 
on the proximal side of the point of operation and destroy 
the gland. 



62 ENTROPIUM OPERA TION. 

Ligation of the duct is accomplished by passing a strong 
silk thread beneath the duct by means of a curved aneurism 
needle, carrying the ligature around the duct and tying 
with a surgeon's knot. The parotid duct may also be 
previously split and an internal wound made at the point of 
ligation. Close the skin wound by means of a continuous 
suture and cover the operative surface with iodoform 
collodion or with wound gelatine. 



9. ENTROPIUM OPERATION. 

Instruments. Razor, scissors, convex scalpel, tenaculum 
and ligation forceps, tenacula, needle holder, needles, thread, 
absorbent cotton. 

Technic. Quiet adult horses may be operated upon in 
the standing position with the aid of local anaesthesia, other 
horses and small animals should be secured in lateral re- 




FlG. I. 
Bntropiutn operation on the superior and inferior eyeUds of the dog. 

cumbency preferably upon the operating table. Shave and 
disinfect the skin of the inverted eyelid. Grasp the skin of 
the eyelid midwa^^ between the inner and outer canthi 
with the forceps and elevate a skin fold parallel with the 
border of the eyelid to such a height that the inverted 
member assumes its normal position. Pass a finger into the 



STAPH YL O TO MY. 63 

conjunctival sac to make sure that the conjunctiva is not 
drawn into the skin fold. Clip the fold off with the scissors 
immediately below the forceps, removing an oblong piece. 
Between the border of the eyelid and that of the wound 
the skin should be left intact for at least .5 cm. Ligate or 
compress any bleeding vessels and close the wound by means 
of interrupted sutures. The wound may be covered with 
iodoform collodion or wound gelatine or dusted over with 
iodoform-tannin. It is usually unnecessary and inadvisable 
to cover the parts with hood or other appliance since so long 
as the wound is healing properly the animal will not disturb 
it. 



10. STAPHYLOTOMY. 



Object. An operation devised by Dr. M. H. McKillip 
for making a manual exploration of the Eustachian tubes, 
guttural pouches, larynx, pharynx and posterior nares ; and 
for operations upon these structures. The form and extent 
of the soft palate of the horse is such as to render it ex- 
tremely difficult to make a manual exploration of the parts 
above and behind it, and impossible to make a visual ex- 
amination except with the aid of the expensive and compli- 
cated rhino-laryngoscope, which only aids in diagnosis while 
staphylotomy combines with this operative advantages, per- 
mitting the free introduction of the hand into the laryngo- 
pharyngeal region. 

Instruments. Mouth speculum, short curved probe- 
pointed bistoury with a ring to fit the middle finger. 

Technic. Cast the patient or secure on the operating 
table in lateral recumbency and turn the nose upward. 
Adjust the mouth speculum and open the mouth as wide as 
possible ; draw the tongue well out with the left hand while 
the right carrying the knife on the middle finger is passed 



64 TRIFACIAL NEUROTOMY. 

carefully through the fauces until it hooks over the posterior 
border of the soft palate. The knife is then gently drawn 
forward making an incision along the median line of the 
soft palate from its posterior, free border to its attachment 
on the palatine bone. The hand is then withdrawn and the 
speculum removed for a few minutes to permit the patient ta 
rid its pharynx of any blood clots or mucus that may have 
accumulated. Readjusting the speculum as before, the 
right hand is again passed through the fauces and now that 
the palate is divided a manual exploration may perfectly 
reveal the presence of any abnormality in the region. 



11. TRIFACIAL NEUROTOMY. 
Plate XIII. 

Object. The relief of involuntary shaking of the head. 

Instruments. Razor, scissors, convex scalpel, tenacula, 
aneurism needle, compression artery forceps, needles, thread, 
absorbent cotton, a strong piece of muslin 12 cm. square. 

Technic. Secure in lateral recumbency, preferably upon, 
the operating table, and produce complete anaesthesia. Re- 
move the halter, bridle, or other headgear. Shave and 
disinfect an area 8 to 10 cm. square over the infra-orbital 
foramen. Locate by touch the infra-orbital foramen, lOF, 
Plate XIII, below the levator labii superioris proprius muscle 
and displace this slightly upward toward the median line of 
the nose until the foramen can be clearly felt below the 
muscle. With the scalpel begin an incision somewhat 
superior to the foramen and near its nasal border and make 
a wound downward and forward in the direction of the 
commisure of the lips about 5 cm. long through the skin, 
muscle and connective tissue down to the nerve and control 
hemorrhage with the greatest care. If the larger branches 
of the glosso-facial vessels are severed they should be ligated 



TRIFACIAL NEUROTOMY. 65 

or twisted. It is even better to ligate or compress these 
vessels prior to severing them. 

Hold the lips of the wound apart with two tenacula or by 
placing a strong suture through each wound margin and 
through the skin at a point 6 to 8 cm. distant and tying the 
sutures tightly, dilate the wound thoroughly and dissect 
aw^ay the connective tissue from the nerve until every part 
of it is clearly in view. Pass an aneurism needle beneath 
the nerve trunk and lifting it from the bone make a search 
for a small artery which usually passes along beneath it 
through the foramen and if this can be found either ligate it 
immediately at its point of emergence and again 5 cm. 
lower dowm and divide between the two ligatures or 
separating it from the nerve protect carefully against injury. 
With a probe-pointed bistoury or scissors sever the nerve at 
the foramen and grasping the distal end dissect away about 
5 cm. of the trunk and excise. Be very careful to include 
all branches and especially one or two superior or dorsal 
twigs which are directed upward just as they emerge from 
the foramen. After the hemorrhage has been brought under 
complete control and all blood clots have been removed 
cleanse the wound carefully, dust over with iodoform and 
close with continuous sutures. 

In order to protect this first wound during the operation 
upon the other side take the piece of muslin mentioned 
among the needs for the operation, and folding it several 
times in a square, place it over the wound and suture it 
firmly at each corner to the skin. Turn the animal to the 
opposite side ai^d repeat the operation on the other nerve 
except the application of the square piece of muslin which 
is here unnecessary. If circumstances will at all permit it 
is far safer to operate upon only one side first, allowing this 
to heal and then operate upon the other side. 

As soon as the animal stands, remove the protective piece 
of muslin from the first wound, disinfect both wounds, dust 
5 



Plate Xlll. 

Trifacial Neurotomy. 

LL, levator labii superioris proprii muscle ; 
lOF, infra-orbital foramen ; NF, superior max- 
illary division of the trifacial nerve. 



LL. 

lOF- 

NF- 



TRIFA CfAL NE C 'RO TO Ml \ 



69 



them over with iodoform and tannin or cover with wound 
gelatine and leave undisturbed to heal by primar}^ union. 
Avoid halter, bridle or other fixtures which might injure 
the wounds after the operation. 

In some cases the operation may be performed upon the 
standing animal under local anaesthesia and whenever this 
is possible it is greatly to be preferred since the hemorrhage 
is far lessened and the danger from sepsis reduced, but with 
most affected animals the standing operation is impractic- 
able. 

Dangers. The chief danger in the operation is from in- 
fection, which sets up a severe neuritis in the proximal end 
of the nerve, aggravates the symptoms and causes much 
suffering. In order to prevent infection the aseptic precau- 
tions need be unusually strict in everj^ detail and the anaes- 
thesia profound. Carefully avoid wounding the neighbor- 
ing vessels and control completel}^ any hemorrhage that 
occurs in order to avoid a hematom in the wound, which 
always invites infection. 

Literature, Involuntary twitching of the head relieved 
by trifacial neurectomy. W. L. Williams, Jour. Comp. 
Med. and V. A., vol. XVIII, p. 426. Involuntary shaking 
of the head and its treatment by trifacial neurectomy, do. 
Am. Vet. Rev., vol. XXIII, p. 321 and CEst. Monatsch. 
Thierheilkunde, Bd. XXIV, s. 211. 



II. OPERATIONS ON THE NECK. 

12. OPENING OF THE GUTTURAL POUCHES. 

Plate XIV. 

Instruments. Razor, Scissors, convex sharp-pointed 
and straight probe-pointed scalpels, artery forceps, tenacula, 
probe, trocar, curette, drainage tubing, suture and dressing 
material. 

Technic. I. Viborg' s method. The operation is possible 
on the standing animal, but generally the patient must be 
cast or placed on the operating table and secured in lateral 
decubitis with the head extended. By extending the head 
and compressing the jugular vein there is brought out the 
triangle immediately behind the posterior border of the in- 
ferior maxilla and below the parotid gland comprised be- 
tween the posterior angle of the inferior maxilla, the 
terminal tendon of the sterno-maxillaris muscle and the 
external maxillary vein. 

In this so-called Viborg's triangle after the removal of 
the hair and the disinfection of the skin which is maintained 
stretched, make a 5 cm. long incision through the skin and 
skin muscle immediately beneath the aforementioned tendon 
and parallel to it. In case of pronounced swelling in 
Viborg's triangle the operator must determine the location 
for the incision by the position of the sterno-maxillaris 
muscle. The skin, subcutem and cervical fascia having 
been incised to a sufficient extent, force a passage with the 
finger or with closed probe pointed scissors or other blunt 
instrument through the loose connective tissue on the 
median side of the parotid gland, to the guttural pouch and 
penetrate it at its lowest point with the finger or trocar. 
In order to open the empty guttural pouch as an exercise 
operation it is desirable to grasp a portion of its wall by 
means of forceps. Through the operative wound a drainage 






OPENING OF THE GUTTURAL POUCHES. 71 

tube can be introduced into the pouch, and fixed in position 
by sutures. The opening can be enlarged in an antero- 
posterior direction to the extent of 5 to 8 cm. or large 
enough to admit the operator's hand. Through this 
enlarged wound, the operator may palpate the Eustachian 
tube and other portions of the interior of the pouch and 
perform desired operations. 

A far more common operation in veterinary practice 
than the opening of the guttural pouches, is the opening of 
strangles abscesses of the sub-parotid lymph glands, lying 
between the inner face of the parotid gland and the external 
face of the guttural pouch. The operation here used is the 
same as Viborg's for the guttural pouch but does not 
penetrate that cavity because the inner wall of the abscess 
has pushed the external wall of the pouch inward so that 
the former largely occupies the usual location of the latter. 
The dyspnoea generally prohibits casting the animal and 
necessitates operating in the standing position. In some 
cases the dyspnoea is so severe as to demand tracheotomy 
before the opening of the abscess can be undertaken because 
the excitement aggravates the difficult respiration to the 
point of suffocation. 

II. ChaberV s inethod. Secure the horse in the lateral re- 
cumbent position, remove the hair and disinfect the skin 
beneath the wing of the atlas. Make an incision about i 
cm. in front of the lower half of the wing of the atlas and 
parallel to it, about 6 cm. long extending through the skint 
and skin muscle down to the parotid gland. The incisioui 
is facilitated by rendering the skin tense with the left hand 
and care is to be taken not to wound the auricular nerve 
which passes directly along the atlas. Then draw backward 
the posterior lip of the wound and separate with blunt in- 
struments the posterior border of the parotid gland from 
the atlas, to which it is bound by loose connective tissue, 
and draw it forward with tenacula. At the bottom of the 



Plate XIV. 

Opening of the Guttural Pouches { Hyoyertebrotomy) 
According to Viborg and Chabert. 

Head and neck of recumbent horse viewed 
from the side, sm, stylo maxillaris muscle ; /, 
parotid gland ; /, guttural pouch ; k, larynx ; 
s^, sterno- maxillaris muscle ; r, rectus capitus 
anticus major muscle ; c, external carotid artery ; 
e, external maxillar}- artery ; i, internal maxil- 
lary artery ; v, external maxillary vein ; s, 
probe ; a, wing of atlas. 



\ 




■^ 



OPENING OF THE GL'TllRAL POUCHES. 75 

Opening thus formed there is seen the stylo-maxillaris 
muscle, sm, Plate XIV, lying against the median side of 
the parotid gland covered only by the aponeurosis of the 
mastoido-humeralis muscle. With the handle of the scalpel 
inclined toward the wing of the atlas penetrate in the 
direction parallel to the long axis of their fibers the aponeu- 
rotic expansion of the mastoido-humeralis, and the stylo- 
maxillaris muscle. The puncture is thus located betw^een 
the ninth and tenth nerves on one side and the internal 
carotid artery on the other. Since the wall of the guttural 
pouch rests against the median side of the digastricus 
or sterno-maxillaris muscle it is opened by this incision. 
The operator inserts an index finger along the blade of the 
knife at first and then withdrawing the instrument passes 
the other index finger also into the penetrant wound and 
by forcibly parting these, dilates it. The abnormal contents 
are then removed by means of forceps, curetting and irriga- 
tion. In order to prevent adhesion of the wound lips in 
the firmly stretched stylo-maxillaris muscle, introduce a 
strong drainage tube into the pouch and fix it to the external 
borders of the wound by a suture. 

III. Dieterich' s method. This operation is effected at a 
point between I and II, the opening of the pouch being 
made immediately behind the stylo-maxillaris muscle. In 
order to accomplish this the cutaneous wound over the wing 
of the atlas must be prolonged below it. After detaching 
the posterior border of the parotid gland the operator 
searches in the loose areolar tissue with the index finger of 
the left hand for the vascular angle which is formed by the 
occipital, internal carotid and external carotid arteries which 
may be detected by pulsation — the same is located at a depth 
of from 8 to 10 cm. Place the volar surface of the finger 
in the vascular angle and push a sharp scalpel along its 
dorsal side to the pouch which here becomes opened on its 
posterior lateral surface. 



y6 TRACHEOTOMy. 

This method has the advantage over Chabert's that for 
the removal of hard contents (chondroids) the opening can 
be readily dilated, even to such an extent that the entire 
hand may be passed into the air sac and the opening of the 
Eustachian tube be explored as in Viborg's operation. 



12. TRACHEOTOMY. 

Fig. 2. 

Instruments. Razor, scissors, convex scalpel, tenacula, 
tenaculum and ligation forceps, trachea tube, and suture 
material. 

Technic. In the superior third of the cervical region, 
in the neighborhood of the fourth to the sixth tracheal ring, 
shave and disinfect the skin on the anterior surface of the 
neck to the extent of lo cm. long b}' 5 cm. wide. The 
operation is best performed upon the standing animal with 
the head extended. In lateral decubitis the operation is 
carried out with some difficulty, and generally the operator 
fails to get the incision on the median line. The operator 
stands before the right shoulder of the horse with an 
assistant opposite him. 

Render the skin tense along the median line of the 
trachea with the left hand and then make a drawing cut 5 
to 8 cm. long from above to below with the scalpel. The 
incision should be made carefully upon the median raphe of 
the skin which is virtually destitute of sensation and requires 
no anaesthesia. After the skin muscle is cut through, in 
order to avoid hemorrhage, separate the two sterno-thyro- 
hyoideus muscles by means of tenacula along the median 
raphe in the white strip of connective tissue. The opening 
into the trachea may be made in a variety of ways. The 
quickest and most crude method is to slit it from above 
downwards through two or three tracheal rings, and press- 



\ 



TRACHEOTOMY. 



77 



ing the several ends apart insert the tube through the open- 
ing. Since the tracheal rings are incomplete, being open 
on their dorsal surfaces, cutting through the ventral portion 
divides each ring into two separate parts and their being 
pushed apart, distorts them and tends to the causation of 
chondritis and collapse of the trachea, a danger which in- 
creases with the duration of time that the tube is maintained 
in position. It is therefore most suitable for hurried opera- 
tion in impending suffocation where the tube will probabl}^ 
be needed for a short time only. 




Fig. 2. 

Tracheotomy, s, sterno-th3'ro-hyoideus muscle ; /, trachea ; 
sch, mucous membrane of the posterior wall of the trachea ; 
/, interannular ligament. 

A second method of operation, illustrated in Fig. 2, con- 
sists in making a transverse incision through the inter-annu- 
lar ligament "between the two last exposed tracheal rings the 
length of the diameter of the tube to be inserted. Make 
a perpendicular incision upward from each end of this at a 
point I to 1.5 cm. from the median line through one or two 
tracheal rings, according to the size of the tube. With 
forceps or tenaculum grasp the segments of partially de- 



78 THE OPERATION FOR ROARING. 

tached cartilage and remove them by cutting through the 
inter-annular ligament. 

A third and to us preferable method is to insert a narrow 
bladed scalpel transversely at about the lower third of the 
lowermost bared tracheal ring and cutting outwards and 
upwards in a curved line, pass through the first inter-annu- 
lar ligament and continue into the succeeding segment until 
near its superior border, when the incision is curved down- 
ward to eventually reach the starting point, the isolated 
section of the trachea being securely grasped wnth a pair of 
forceps before its excision is completed. By this method 
no tracheal ring is severed. 

The trachea tube is to be removed and cleansed daily as 
long as its use is necessary, and when discontinued the 
wound should be left open and dressed antisepticall}^ 



13. THE OPERATION FOR ROARING. 
Plate XV. Figs. 3-5. 

Instruments. Razor, hypodermic syringe, scalpels, 
tenaculum, artery forceps, laryngeal speculum, two long 
curved dressing forceps, hard rubber syringe with long pipe, 
ventricular burr, reflecting lamp, razor-shaped scalpel, long 
curved scissors. 

The following technic has for its aim two fundamental 
objects which are to be kept constantly in mind : 

I. It is aimed to bring about a prompt, firm, complete 
and permanent adhesion of the arytenoid cartilage and vocal 
cord against the inner face of the thyroid cartilage in the 
normal position of forced inspiration, so that no air can 
become impacted into the ventricle to force the vocal cords 
and arytenoid cartilage downwards and inwards to obstruct 
the free ingress of air. 



\ 



THE OPERATION FOR ROARING. 79 

2. It is aimed to complete the operation without wound- 
ing a cartilage either in the essential operation when re- 
moving the ventricular mucosa, during the invading incision 
through the crico-thyroidean membrane, and later, should 
dyspnoea occur, by inserting the laryngeal tube through 
the existing incision instead of performing tracheotomy. 

Technic. Docile animals are readily operated upon in 
the standing position. The animal should be confined in 
stocks, or otherwise, in such a manner that his head may 
be securely held in an elevated and extended position. The 
safety of the operator further demands that the patient 
shall be so secured that he can neither rear nor strike. 

Resistant animals need be cast or confined upon the 
operating table. General anaesthesia upon the recumbent 
animal is usually unnecessary, and is only demanded in those 
cases of unusual resistance to confinement, where the patient 
may injure itself by its violent struggles. 

Ordinarily ample anaesthesia, whether from the stand- 
point of surgical efficiency or of sentiment, is obtainable b}^ 
the use of local anaesthetics, preferably of cocaine and 
adrenaline. 

Shave and disinfect the operative area, and inject sub- 
cutaneously a sufficient amount of the local anaesthetic. 

Make a longitudinal incision over the larynx through the 
skin and fascia as accurately as possible on the median 
raphe, commencing opposite to the anterior extremity of 
the thyroid cartilage and extending downward and back- 
ward to the region of the first tracheal ring. Separate the 
sterno-thyro-hyoideus muscle on the median line with the 
scalpel blade "or handle as preferred. Control the hem- 
orrhage. If the operation is performed upon the standing 
animal with the aid of cocaine and adrenaline, the incision 
is virtually bloodless. 

Locate the crico-thyroidean ligament, triangular in form, 
bounded anteriorly and on both sides by the thyroid cartilage 



Plate XV. 
Operation for Relief of Roaring. 

Fig. I. Longitudinal section through the 
ventricle of the larynx ; A, arytenoid cartilage ; 
TA, anterior fasiculus of thyro-arytenoideus 
muscle; TA^, posterior bundle thyro arytenoid- 
eus ; VC, vocal cords ; V, laryngeal ventricle ; 
T, thyroid cartilage ; E, epiglottis. 

Fig. 2. Sagittal section of the larynx. C, 
cricoid cartilage. Other lettering same as Fig. i. 



\ 



TA y tX ,VC 




Fig. 1. 




Fig. 2. 



THE OPERA TION FOR ROARING. 



83 



and posteriorly by the cricoid ring. Error may occur here 
and the space between the cricoid and first tracheal rings be 
mistaken for the crico-thyroidean ligament. This is readily 
obviated by careful digital palpation, which reveals the 
triangular crico-thyroidean ligament with its rounded apex 
directed forward and its lateral borders sharply defined by 
the hard borders of the alse of the thyroid cartilage, while 
the base of the triangle rests upon the more elastic anterior 
border of the cricoid cartilage. 




Fig. 3. 

Laryngeal dilator in position. 

Having carefully identified the crico-thyroidean ligament, 
place the back of the scalpel against the anterior border of 
the cricoid cartilage, accurately upon the median line, the 
point directed obliquely backwards toward the cavity of the 
trachea. Push the scalpel through the ligament into the 



84 THE OPERA TION FOR ROARING. 

laryngeal cavity, and carry the incision forwards on the 
median line to the body of the thyroid cartilage. 

Detach the slotted piece from the laryngeal retractor (Fig. 
4) and insert the closed retractor into the incision through 
the ligament, the ratchet end of the speculum being directed 
toward the trachea, the curved spurs on the jaws of the 
retractor resting within the cricoid ring. Open the dilator 
to the full extent of the crico-thyroidean space. Insert the 
hook of the slotted piece into the cavity of the thyroid 
cartilage and secure in position by means of the thumb screw. 

Illuminate the cavity of the larynx. In the standing 
animal, when facing good light, the natural illumination 
suffices. The illumination may be improved with the aid 
of a hand mirror. 

Excellent illumination is always available by means of a 
reflecting electric lamp. With a good lamp the illumination 
may be perfectly controlled in a dark room or in the dark- 
ness of night. When the animal is cast and turned upon 
his back, the light rays should enter the larynx from above 
obliquely downward and forward. If the operation is being 
done in the open field by sunlight, the patient's head should 
be directed away from the sun, or good illumination fails. 

Observe the motion of the arytenoid cartilages, and 
determine, if not previously done, whether the unilateral or 
bilateral operation is to be performed. Inject into the 
larynx and laryngeal ventricle or ventricles a sufficient 
quantity of a solution of cocaine and adrenaline to blanch 
and anaesthetize the mucosa. The ventricles are more con- 
veniently injected if the syringe nozzle is bent near the tip. 

The ventricles commonly contain some mucus, which 
interferes with the securing of the mucosa and should be 
taken up and removed by means of a small piece of absorbent 
cotton pressed into the ventricle with the long curved dress- 
ing forceps. 

When the ventricular mucosa has been effectively anaes- 
thetized introduce the burr into the ventricle and draw the 

\ 

% 



THE OPERATION FOR ROARING. 



sheath on the burr shaft away from the burr for the distance 
of about I cm. Press the burr gently against the bottom of 
the ventricle, hold the canula to prevent its revolving, and 
give the burr one or two turns to the right until the re- 
sistance indicates that the mucosa is securely engaged. 
The canula is now pushed against the burr and gentle 
traction applied to the handle, revolving the burr and canula 




Fig. 4. Fig. 5. 

Laryngeal dilator. Ventricular burr, modified 

after Blattenberg. 

now and then a trifle, until the everted mucosa from the 
bottom, of the ventricle appears beyond the mouth of the 
ventricle. Grasp the everted portion of the mucosa securely 
with the long curved dressing forceps and then continue 
traction with these until the ventricular mucosas has been 
completely everted. Then cut away the everted mucosa by 
excising it with the razor-shaped scalpel or by means of 



86 THE OPERATION FOR ROARING. 

long scissors at approximately the point indicated by the 
dotted Hne in Plate XV. 

If the right side of the larynx appears to be affected also, 
or if for other reasons it seems desirable, repeat the operation 
upon the right ventricle. 

(The operation may also be performed without the use of 
the ventricular burr, but it is more difficult, especially upon 
the standing animal. The technic is the same until the 
removal of the ventricular mucosa is reached, when, instead 
of the burr, the mucosa of the ventricle at its arytenoid 
border is grasped with the forceps, tension is applied, and 
the mucosa is incised along the arytenoid border and thence 
along the summit of the vocal cord. The incision is con- 
tinued at the point indicated by the dotted line in Plate XV 
until the ventricular mucosa has been isolated from that of 
the larynx in general. Cautiously exerting tension with 
the forceps upon the incised border of the ventricular 
mucosa, dissect it away from the loose underlying areolar 
connective tissue either with the Moeller razor-shaped 
scalpel or with a scalpel handle.) 

However the mucosa is removed the operator should take 
care that the removal is complete, since any remnant 
incautiously left behind in the ventricle may prevent the 
desired adhesion of the arytenoid to the thyroid cartilage or 
a small patch of mucosa being left deep in the ventricle 
might permit adhesion of other parts, imprisoning the 
mucous islet and ending in a mucous cyst. 

When the mucosa has been removed from one or both 
ventricles, all blood coagula should be wiped away, any 
shreds of tissue removed and the denuded tissues painted 
over with tincture of iodine. The application of the tincture 
of iodine is best made with the long curved dressing forceps 
carrying a small pledget of cotton saturated with the drug. 
The operator needs have care in this application lest the 
horse in forcible expiration blow some of the iodine in his 
face and eyes. 

\ 
% 



THE OPERA TION EOR ROARING. 



87 



If the patient has been cast, anaesthetized and turned 
upon his back, turn him upon his side, remove the confining 
apparatus, and, while he is recovering from the anaesthesia, 
keep the laryngeal incision open and the larynx free from 
blood. The hemorrhage from the operation is the greatest 
when it has been performed under general anaesthesia, less 
if cast and the operation performed under local anaesthesia 
and by far least of all when it is performed upon the stand- 
ing animal with the aid of cocaine- adrenaline anaesthesia. 

As soon as the operation has been completed upon the 
standing animal, the head may be released and the patient 
returned to the stall. It may be allowed to eat or drink at 
convenience. The same is true of the patient cast for the 
operation, and only local anaesthesia applied. Patients 
cast and chloroformed should be prevented from eating or 
drinking for some hours and should be fed sparingly for 
three or four days. 

During the first 48 hours after operating, especially after 
the bilateral operation, the patient should be closely watched 
in reference to dyspnoea either from hematoma in the 
ventricles or from edema or emphysema of the parts. If 
dyspnoea becomes at all apparent, tracheotomy should be 
promptly performed, or what we greatly prefer, a laryngeal 
tube should be inserted and fixed securely to the margins 
of the external wound by means of stout sutures, and further 
security given by passing strong tapes about the neck and 
tying firmly. 

Ordinarily the ventricular wounds should not be disturbed: 
after the operation. The external wound should be dressed 
antiseptically daily till healed ; a period of about three 
weeks. Horses used for ordinary work purposes may 
usually be returned to their work after five to six weeks. 



^8 INTRA VENOUS INJECTION. 

14. INTRA-TRACHEAL IRRIGATION. 

Dbjects. The washing out of oils or other insoluble or 
irritant substances accidentally introduced into the trachea 
and bronchi while drenching or otherwise, and the disin- 
fection of the trachea and bronchi. 

Instruments, Same as for tracheotomj^, and a gravity 
irrigating apparatus fitted with 3 m. of rubber tubing about 
I cm. in diameter, 5 liters of .6 per cent, sodium chloride 
solution at a temperature of 37 to 39° C. In cases of 
suppurative bronchitis, peroxide of hydrogen may be added 
to the solution. 

Technic. Operate on the standing animal. Perform 
tracheotomy (page 76). Elevate the gravity apparatus 
containing the irrigating fluid i to 2 m. above the patient, 
have the animal's head slightly elevated, insert the free end 
of the rubber hose in the trachea tube and let the fluid flow 
into the trachea in a moderate stream until it is filled and 
the animal makes expulsive efforts, when the inflow is 
stopped and the animal permitted to lower his head and 
expel the fluid, then raise the head again and repeat until 
the fluid is expelled clear. Repeat the operation according 
to requirement. 



15. INTRAVENOUS INJECTION. 
Fig. 6. 

Instruments. Scissors, hypodermic syringe. 

Technic. The operation is performed on the standing 
animal on either jugular vein at about the juncture of the 
upper and middle thirds of the neck ; to most operators the 
right jugular is the more convenient. At the place desig- 
nated the subscapulo-hyoideus muscle lies between the 
jugular vein and the carotid artery and affords some pro- 
tection against injury of the latter. After clipping the hair. 



\ 



INTRAVENOUS INJECTION. 89 

the skin should be carefully disinfected preferably with 
tincture of iodine. The vein lies in the jugular groove 
between the mastoido-humeralis and the sterno-maxillaris 
muscles covered only by the skin and skin muscle. 

Stand by the shoulder of the horse and compress the 
jugular with the thumb as shown in Figure 6 or with the 
second to the fourth fingers, in which case the ball of the 
thumb rests on the mastoido-humeralis muscle, in a way that 
the vein becomes filled above the point of compression in the 




Fig. 6. 

Intravenous Injection. 

shorn area and stands out as a swollen cord. In the case 
of fleshy necked horses efficient compression is more readily 
attained if the head is somewhat elevated and extended by 
an assistant. If the vein cannot be made prominent in this 
way the compression should be alternately applied for a 
time and then withdrawn suddenly, when the course of the 
vein reveals itself by a wave-like movement along the 
jugular groove. 



go INTRA VENO US INJECTION. 

In cattle digital compression of the jugular is not usually- 
efficient in causing distension. It is more practical to dis- 
tend the jugular by passing a looped cord around the base 
of the neck and drawing it tightly. The very conical neck 
of the cow tends to cause the cord to slip forward and loosen, 
which may be obviated by having an assistant grasp the 
cord at the top of the neck and hold it in place. A very 
efficient method for distending the jugular of the cow is to 
stretch a strong cord tightly between two posts at the 
heighth of the base of the neck, lead the animal against it 
and secure the head firmly to a post in front of the animal 
sufficiently tight to cause the lower part of the neck to 
press firmly against the cord. 

Just above the point of compression the vein is the most 
fully distended and firmly fixed. After testing the hypo- 
dermic needle to see that it is open hold it between the 
second and third fingers while the thumb covers its basal 
opening and thrust it through the skin, cutaneous muscle 
and jugular wall, in the direction of the vein obliquely for- 
wards and upwards i to 2 cm. deep, so that the point of the 
needle enters the vessel at its most distended part. In this 
way it is easy to prevent injury to the median wall of the 
vein. If the vein has been properly punctured blood will 
flow from the needle upon the removal of the thumb. If 
the vein is not entered at the first attempt the needle should 
be partly withdrawn and then pushed in again in a slightly 
different direction. 

Be careful that the hypodermic syringe contains no 
air. The material to be injected should be wanned to approxi- 
mately the body temperature. The syringe is then connected 
with the needle and the contents slowly discharged into the 
vein. In withdrawing the needle be careful to press the 
skin firmly against the underlying part. The omission of 
this precaution frequently results in the formation of a 
subcutaneous hematome. 



\ 



PHLEBOTOMY. gi 

16. PHLEBOTOMY. 

Fig. 6. 

Instruments. Razor or scissors, fleams, lancet, phle- 
botomy trocar, spring lancet, pins, suture material. 

Technic. a. Phlebotomy luith flearns may be performed 
on either jugular vein. The operation is preferably carried 
out on the standing animal, but is not difficult when the 
patient is recumbent. The point of operation is at about 
the boundary line between the upper and middle cervical 
regions, because it is here that the subscapulo-hyoideus 
muscle which separates the jugular vein from the carotid 
artery is most voluminous and consequently affords the 
greatest protection to the latter. At this point clip or shave 
and disinfect the skin. Grasp the extended blade of the 
fleam at the hinge with the thumb and index finger of one 
hand, while the third and fourth fingers compress the 
jugular vein at a point far enough below that the fleam 
blade rests upon the shaved part. In fleshy-necked animals 
the course of the vein may be clearly made out by causing 
its repeated distension and relaxation. In some very heavy 
necked horses, or in very restless animals, efficient distension 
of the jugular is best obtained by cording the neck as 
described under "Intravenous Injection." 

It is well to be careful that the point of the fleam blade is 
not allowed to prick the skin prematurely and render the 
animal restless. The instrument should be held perpen- 
dicular to the surface and parallel to the long axis of the 
vein. The most elevated point of the vessel should be 
struck by the blade in such a way that the skin, subcutan- 
eous muscle and jugular wall are penetrated parallel to the 
long axis of the vessel. 

Drive the fleam blade into the vein by a short, sharp blow 
with a small stick of heavy wood. The extension on the 
fleam blade prevents its being driven too deeply. The size 



92 PHLEBO TOM Y. 

of the blade to be used depends upon the thickness of the 
skin and other tissues covering the vein. If the vein is 
opened, dark red blood escapes from the wound in a large 
stream. If the operation does not succeed at the first effort, 
one should select an undamaged portion of the skin for a 
second attempt so that the opening into the vein may be 
direct and clean. 

When the vein is opened lay the instrument aside. The 
compression of the vessel must be continued in order to 
insure the flow of blood, to prevent aspiration of air and 
also to provide that the lips of the skin wound shall not be- 
come displaced in relation to that of the vein by which the 
escape of blood would be impeded or stopped. The flow of 
blood may be favored by inducing masticatory movements 
by the animal. The amount of blood withdrawn varies 
between 3 and 8 liters, according to the size of the animal and 
the object to be attained. 

The wound may be closed by an interrupted or a pinned 
suture. For the latter, relieve the compression on the vein 
and grasp the lips of the skin wound between the finger and 
thumb and stick the pin perpendicularly through the middle 
of them a few mm. from their borders. Apply a noose of 
silk ligature, previously prepared, over the pin and close and 
tie the loop. In applying the pin and loop, take care not 
to elevate the skin from the underlying part, which tends 
to the production of a hematome. 

b. With the lancet the operation is preferably performed 
on the right side of the neck. Compress the vein as illus- 
trated in Fig. 6, and hold the lancet between the thumb 
and index finger in such a manner that it can only penetrate 
as far as into the vein, and then push it in quickly just in 
front of the compressing thumb through the skin, subcutem 
and venous wall as deep as the fingers holding the lancet 
will permit. 

Hold the blade perpendicular to the long axis of the vein, 
and avoid directing the point dorsalwards, which would 

\ 

% 



LIGATION OF THE CAROTID ARTERY. 93 

endanger the superior wall of the vessel or cause the lancet 
to glide over the wall and not enter the vein. When the 
lancet has entered the vein, extend the wound somewhat 
toward the head by flexing the hand dorsally. In cattle it 
is necessary to compress the vein by means of a cord tightly 
drawn around the neck, the operator taking the same posi- 
tion as in the horse while an assistant holds the animal by 
the horns or nose, or the vein may be still more effectively 
distended by causing the patient to press against a tightly 
stretched cord with the base of the neck as advised for 
intravenous injection on page 88. Close the wound as in a. 

Phlebotomy with the spring lancet is carried out in a 
similar manner, the jugular being compressed in the same 
way, and the lancet, with the spring set, placed over the 
vein in such a way that the opening will be made in the 
same direction and manner as with the fleams. The lancet 
blade is then released and penetrates the vein. The com- 
pression below is continued as in other cases. 

c. Phlebotomy zvith the trocar is performed in the same 
manner as has been described for intravenous injection. So 
long as the flow of blood continues the compression of the 
vein must not be intermitted. The phlebotomy trocar 
should be about 5 mm. in diameter. 



17. LIGATION OF THE CAROTID ARTERY. 
Plate XVI. 

Objects. The control of hemorrhage from wounds or 
the preventk)n of hemorrhage during the removal of tumors 
or other operations in the parotid region. 

Instruments. Scissors, scalpel, tenacula, aneurism 
needle, mouse-toothed forceps, ligation forceps, suture 
material. 

Technic.^ The operation is possible on the standing 
animal with the aid of cocaine or other local anaesthetic but 




Plate XVI. 

Fig. I. — a, Ivigation of the common 
carotid artery ; b, CEJsophagotomy. 

Fig. 2. — Ligation of the common 
carotid artery ; c, common carotid 
artery;/, jugular vein ; z\ vagus nerve; 
s, sympathetic nerve ; r, recurrent 
nerve ; p, cervical panniculous carno- 
sus muscle ; in, sternomaxillaris mus- 
cle ; sf, levator humeri muscle. 

Fig. 3. — CEsophagotomy. ^, com- 
mon carotid artery; 7, jugular vein ; 
o, o\ oesophagus ; s, sympathetic 
nerve ; /, trachea ; st, mastoido-hum- 
eralis (lavator humeri) muscle. 





mz : 



Fig. 1. 




Fig. 3. 



LIGATION OF THE CAROTID ARTERY. 97 

it is preferable to confine the patient in laternal recumbency 
and anaesthetize. 

The operation is made at the same point as for phlebotomy 
and the same cutaneous wound, a, Plate XVI, may be used 
for this purpose. The incision should be at least 10 cm. 
long extending through the skin, flesh}^ panniculus and 
subscapulo-h3^oideus muscles and then a passage forced with 
the fingers to the trachea. At the region of the neck indi- 
cated, the carotid passes along the border between the 
lateral and dorsal surfaces of the trachea, accompanied 
dorsally by the vagus and sympathetic nerves and ventrally 
by the recurrent. (In Fig. 2, Plate XVI, the vagus and 
sympathetic nerves, v and s, are pushed out of their normal 
position and appear ventrally to the carotid.) Pass the 
index finger over and behind the carotid until the trachea 
is reached, and encircling the inner and lower sides of the 
artery, force a way through the surrounding areolar tissue 
and draw the vessel out through the wound. As a rule 
the carotid is still loosely surrounded by connective tissue, 
which comes from the deep fascia of the neck and in which 
also the three above mentioned nerves are found. These 
nerves must be carefully separated from the carotid and 
must on no account be included in the ligature. Ligate 
the carotid twice with an interval of about 2 cm. between 
the two ligatures and divide the arterj^ midway between 
them. The second ligature is necessary in order to prevent 
hemorrhage from the distal end through collateral anasto- 
moses and it is essential to sever the artery in order to avoid 
its rupture by the stretching of the undivided carotid dur- 
ing movements of the neck where the nutrition has been 
cut off at the point of ligation. Provide drainage for the 
wound and suture the muscle and skin. 



gS OESOPHAGOTOMY. 

18. OESOPHAGOTOMY. 
Plate XVI. 

Instruments. Razor, scissors, convex scalpel, straight 
probe-pointed bistoury, tenacula, artery forceps, absorbent 
cotton, suture material. 

Technic. The operation can be carried out on the 
standing or the recumbent animal. At its origin the 
oesophagus lies above the trachea somewhat to the left of 
the median line and as it decends it gradually deviates 
farther until in the lower cervical region it lies down along 
the left side of the trachea. 

The operation is performed at any point between the 
pharynx and chest w^here the lodgment of a foreign body 
or other condition may demand it. When the cesophagus 
is empty the operation is best performed in the lower third 
of the neck at b, Fig. i, Plate XVI. 

An incision lo cm, long through the skin and skin muscle 
is made on the left side between the anterior border of the 
mastoido-humeralis muscle and the jugular vein. With the 
two index fingers divide the loose connective tissue down to 
the cesophagus, which lies between the left scalenus muscle, 
trachea and jugular vein. Along the supero-external 
border of the trachea runs the carotid artery, accompanied 
dorsally by the vagus and sympathetic and ventrally by the 
recurrent nerves. The oesophagus feels like a round muscle 
within which one can distinguish a firmer cord, the mucous 
membrane. When brought into view the organ has a pale 
red color, and it, with the trachea is surrounded by the 
deep fascia of the neck. Pass one finger around the 
oesophagus from behind, draw it away from the trachea, 
force a passage through the deep fascia of the neck and 
draw it out through the external wound. After making an 
incision through the oesophageal muscle and mucous mem- 
brane introduce a probe pointed bistoury or a scissors blade 



OESOPHAGOTOMY. gg 

into the lumen of the oesophagus and split its wall. The 
mucous membrane is white and lies in thick longitudinal 
folds. 

When there is a foreign body in the oesophagus the 
operation is performed at the point where it is lodged, in 
the manner described and the incision should be made only 
large enough to permit its removal. In diverticuli of the 
oesophagus an ellipical piece of the mucous membrane 
which has been overstretched is cut out. The oesophageal 
wound is closed by a laminated suture, that is, the mucous 
membrane is united by means of an intestinal suture and 
the muscular wall closed over this. The skin and muscular 
wound may either be left open or closed with the Bayer 
suture and bandaged, with a drainage tube in the lower 
angle. 



III. OPERATIONS ON THE TRUNK AND 
GENITAL ORGANS. 

19. PUNCTURE OF THE CHEST. 

Fig. 7. 

Objects. The relief of hydrothorax or pyothorax. 

Instruments. Razor, scissors, trocar, i m. of rubber 
tubing of the same size as the trocar, vessel for receiving 
the escaping fluid, dressing material. 

Technic. Operate upon the standing animal, the point 
of operation in the horse being the seventh intercostal space 
on the left side, and the sixth on the right. Dogs may be 







Fig. 7. 

Puncture of the chest ; puncture of the intestine. 

laid upon the table. The anterior ribs are so covered by 
the shoulder that they cannot be counted from before back- 
wards and must be enumerated from behind forwards. In 
the horse there are usually eighteen ribs and in the dog 
fourteen. Counting ii or 12 intercostal spaces from behind 



PUNCTURE OF THE INTESTINES. loi 

we reach in the horse the point of operation on the left and 
right sides respectively. Clip or shave the designated inter- 
costal area immediately above the thoracic vein. Grasp the 
trocar firmly with the thumb and index finger of one hand 
at such a distance from the point as will permit the canula 
to enter the chest. After the skin over the seat of operation 
has been drawn aside by the hand, place the trocar at the 
anterior border of the rib with the point inclined slightly 
forward and with a sharp blow with the palm of the other 
hand drive the instrument through the skin, cutaneous and 
intercostal muscles, internal thoracic fascia and pleura into 
the pleural sac. When the resistance ceases, the thoracic 
cavity has been entered. Remove the stilette and permit 
the pus, lymph, or other fluid to escape. This flow is at first 
continuous, but later becomes rythmic, synchronous with 
respiration. The intermission of the flow during inspiration 
permits air to enter the pleural cavity unless precautions 
are taken against it ; this is most readily obviated by slipping 
one end of the rubber tubing over the exposed part of the 
canula and placing the other extremity in the receptacle for 
the fluid where it will be submerged. This will not onl}^ 
prevent aspiration of air into the chest but will act as a 
siphon to aid in the withdrawal of the fluid from the pleu- 
ral cavity. In the absence of the tubing the entrance of 
air may be avoided by closing the canula with the finger 
after each expiration. 



20. PUNCTURE OF THE INTESTINES. 

Figs. 7-8. 

Object. The rehef of intestinal tympany. 

Instruments. Razor, scissors, trocar. 

Technic. Puncture of the intestine is preferably per- 
formed on the standing horse but may be carried out on the 
recumbent animal. The point of operation is in the right 



I02 PUNCTURE OF THE INTESTINES. 

flank about equi-distant from the last rib, the extremities 
of the transverse processes of the lumbar vertebrae and the 
external angle of the ilium in the standing horse ; at the 
uppermost point of the abdomen in the recumbent animal, 
that is, at the most prominent part of the distension. After 
the skin at this place has been clipped or shaved and disin- 
fected gasp the trocar with the index finger and the thumb 
of the left hand and holding the instrument perpendicular 
to the body surface, give it a firm, quick blow with the 
palm of the right hand and drive it through the abdominal 
wall into the intestine. 

With a properly constructed trocar of the dimensions 
suggested in Figure 8 no preliminary puncture with the 
lancet is required or advisable. The cutting end of the 
stilette should be very long, tapering and sharp so that it 
will cut as freely as a lancet. By performing the opera- 
tion as directed the trocar ordinarily punctures the caecum. 



Fig. 8. 

Intestine trocar with sheath. Outside diameter of canula 3 mm., 
length of canula, 16 cm. 

Withdraw the stilette and permit the gas to escape 
through the canula. The canula may become occluded by 
particles of ingesta entering it and these should be removed 
by reinserting the stilette. The intestine first punctured 
may collapse and the flow of gas cease while the tympany 
continues in other parts ; this may be overcome by reintro- 
ducing the stilette and pushing the trocar through the 
distal wall of the bowel and into the intestine beyond. If 
this does not succeed, the trocar may be withdrawn and 
reinserted in a neighboring area or if need be on the 
opposite side of the animal. 



SUBCUTANEOUS CAUDAL MYOTOMY. 103 

In withdrawing the canula replace the stilette and press 
the skin against the abdomen with the thumb and finger of 
one hand while the trocar is drawn out with the other. 
This tends to prevent particles of ingesta from following 
the canula out of the intestine and becoming lodged at 
some point in the track of the wound to set up inflammatory 
processes there. 

Before introduction, the trocar should always be rendered 
sterile but should not bear irritant antiseptics, which be- 
coming lodged in the wound tend to irritate the tissues and 
produce abscesses. Puncture of the intestine is so often 
extremely urgent that deliberate aseptic precautions are not 
always practicable and trocarization only too frequently 
results in abscesses in the abdominal wall. Its prevention 
must depend chiefly upon the disinfection of the skin and 
instrument. It becomes important to use an instrument 
which is clean in advance. If the one one shown in Fig. 8 
is well disinfected after using and the sheath is filled with 
alcohol before it is screwed on, the instrument will remain 
sterile until it is again unsheathed when the alcohol will 
quickly evaporate and leave the trocar aseptic. 



21. SUBCUTANEOUS CAUDAL MYOTOMY. 
Fig. 9. 

Object. The correction of curved tail. 

Instruments. Sharp straight tenotome, bandage. 

Technic. The point or points of curvature and their 
extent are toTDC carefully noted by having the animal trotted 
away from the operator. The curvature is generally due to 
unequal development of the two levator or extensor muscles, 
Fig. g.-e, though quite rarely the depressors,/ may be 
implicated. 



J04 



SUBCUTANEOUS CAUDAL MYOTOMY. 



Confine the animal in stocks, or in default of these, con- 
trol by means of a twitch and sideline. Cleanse and disin- 
fect the tail and have it sharply bent by an assistant in the 
opposite direction to the curvature. Locate the longitudi- 
nal furrow between the levator and depressor muscles on 
what has now become the convex side and at the lower 
margin of the levator and just above v, Fig. 9, insert the 
tenotome at the most prominent part of curvation, the 
incision being parallel with the muscular fibers, and push 




Fig. 9. 

Transverse section of the tail, n, caudal vertebra ; c, sacro- 
coccygeus lateralis muscle ; e, sacro coccygeus superior ; /, 
depressor longus and brevis muscles (sacro-coccygeus infer- 
ior); i, intertransversales muscles ; a, coccygeal artery ; s, su- 
pero-lateral coccygeal artery ; /, infero-lateral cocc3'geal ar- 
tery ; z', caudal veins (dorsal, ventral, lateral) ; 5r//, caudal 
fascia ; k, skin. 

the instrument entirely through the muscle to the vertebra, 
then turning the cutting edge upwards, at the same time 
advancing the point toward the median line, sever the 
entire muscle. 

The superior lateral caudal artery, s, Fig. 9, bleeds pro- 
fusely if severed, and wounding of it may usually be 
avoided by withdrawing the tenotome a trifle in passing 
that point. 



CAUDAL MYECTOMY. 105 

Wounding the skin over the muscular incision is avoided 
by placing the thumb of the left hand over the line of in- 
cision so the knife will be recognized as soon as the muscle 
and caudal fascia are cut through. Remove the knife in the 
same manner as introduced. Release the horse and have 
him trotted again. If the operation is sufficient, the tail 
shoidd curve in abotit the same degree as before, but in the 
opposite direction. If this has not been attained examine 
carefully and sever any remaining bundles of muscle, and 
this not sufficing repeat the operation as before at another 
point 5 or 6 cm. above or below the first, severing the muscle 
again. Or if the depressor appears implicated, sever it in 
a similar manner. In extreme cases the entire lateral half 
of the caudal muscles, tendons and aponeurosis may be 
severed. 

Apply an antiseptic pad to the wound and retain it by a 
moderately firm bandage, which serves at once as an occlu- 
sive dressing and effective hemostatic. Remove the band- 
age after 24 hours. By this plan of operation it is not 
intended to tie the tail to the side of the animal during the 
time of healing but when bandaging immediately after the 
operation, the tail should be held away from the side toward 
which it formerly curved so that the bandage may tend to 
prevent the return of the organ to its former position. 



22. CAUDAL MYECTOMY. 
Fig. 9 and Plate XVII. 

Objects. For the prevention of the gripping of the reins 
by the tail. 

Instruments. Elastic ligature, straight bistoury, ten- 
acula, absorbent cotton, bandages. 

Technic. Confine the animal in lateral decubitis or in 
stocks, cleanse and disinfect the parts and apply the elastic 



Plate XVIL 

Caudal Myectomy To Prevent Gripping 
of the Reins. 

DC, Depressor coccygeus lougtis muscle ; T, 
tourniquet. 



DC- 




llhii.'iJS 



AMPUTATION OF TAIL. 



109 



ligature as close as possible to the root of the tail. Have 
an assistant hold the tail upwards, i. e., dorsalwards, and 
tightly stretched. Make an incision 15 to 20 cm. long, over 
the middle of the inferior surface of each depressor longus 
muscle, beginning close against the elastic ligature and ex- 
tending toward the apex, severing at once the skin and 
caudal fascia down to the muscle. Let an assistant retract 
the lips of the incision with tenacula while the operator 
dissects the depressor longus muscle, DC, Plate XVII, from 
the adjacent tissues at either side, sever it by a transverse 
incision close against the ligature and dissect aw^ay the en- 
tire muscle down to the lower end of the w^ound and there 
excise it. Repeat the operation on the opposite side. 

Make tw^o elongated tampons of absorbent cotton, of the 
size and form of the muscles removed, saturate these with 
I -1000 sublimate solution, insert neatly in the wounds and 
over this to aid in securing antisepsis and to equalize the 
pressure apply a pad of absorbent cotton, saturated with 
sublimate solution, covering the wounds and encircling the 
tail and secure by a moderately firm bandage as closely as 
possible to the elastic ligature. Remove the ligature, when 
hemorrhage may ensue, which is to be controlled by the ap- 
plication of a second bandage extending higher up on the 
tail. Remove the bandage in 24 hours and dress as before 
for a second day after which treat as an open wound. Care 
should be taken to not apply the bandage too tightly or 
leave it in place for more than 24 hours, since otherwise 
necrosis of the tail is liable to occur and necessitate 
amputation. 



23. AMPUTATION OF THE TAIL. 
Plate XVIII. 

Objects. The treatment of malignant, or incurable dis- 
eases of the tail. 

Instruments. Elastic bandage, scalpel, razor, artery 
forceps, bone cutting forceps, suture material. 



Plate XVIII. 
Amputation of the Tail. 

Fig. I. — Tail amputated showing flaps un- 
sutured ; B, Bandage securing hairs turned 
upward out of operator's way. 

Fig. 2. — Operation completed showmg su- 
tures ; B, Bandage applied to secure hairs of tail 
upwards out of operator's way. 




Fig. 1. 




Fig. 2. 



AMPUTATION OF THE TAIL. 113 

Technic. The animal may generally be operated upon 
in a standing position secured in the stocks or with the aid 
of the side line. Local anaesthesia may be applied by in- 
jecting cocaine or other drug deeply upon the nerve trunks 
as well as just beneath the skin. The animals' attention 
may be attracted by means of the twitch if found necessary. 
The point of amputation is determined by the location of 
the disease. Over the area of operation clip the hair, shave 
and thoroughly disinfect. Apply the tourniquet or elastic 
bandage at the base of the tail so as to render the operation 
bloodless. 

Above the seat of operation turn the hair upward toward 
the root of the tail and secure it there by means of the 
bandage, B, Fig. i, Plate XVIII. Locate as accurately as 
possible the position of a joint at the point where it is desired 
to operate and with the scalpel begin an incision on the 
median line on the upper side of the organ about i cm. 
above the articulation and carry this obliquely outward for 
a distance of 4 to 6 cm. according to the size of the tail and 
then continue it downward, backward and inward along the 
side and inferior surface until directly opposite to the place 
of beginning. Make a similar incision upon the opposite 
side of the tail, cut through all the connective tissue and 
muscles down to the bone and then disarticulate with the 
aid of the scalpel. Search for the arteries and control the 
hemorrhage by torsion or ligation. The vessels will be 
more readily found by loosening the tourniquet so as to 
permit the blood to flow. 

Some operators prefer to begin the incision at the side of 
the tail instead of upon the dorsal surface and in that way 
have a dorsal and ventral flap instead of right and left as 
indicated in Fig. i, Plate XVIII. The excision having been 
completed the flaps are brought together by means of strong 
silk or silk worm gut sutures as shown in Fig. 2. The 



114 



URETHROrODFY. LITHOTOMY. 



sutures should be begun at the apex of the two flaps and 
comparatively deep. 

Disinfect the stump thoroughly and if the hair is suffici- 
ently long it is well to draw it down over the wound, 
to which an antiseptic covering has been applied, and retain 
the dressing in position by tying a cord around the hair just 
beyond the point of amputation. 



24. URETHROTOMY. LITHOTOMY. 
Figs. 10-11. 

Objects. For the removal of calculi from the bladder 
or urethra or performing other operations on these parts. 

Instruments. Catheter, convex scalpel, scissors, artery 
and compression forceps, tenacula, lithotome, lithotomy 
forceps, lithotrite, absorbent cotton, drainage tube, suture 
material. 

Technic. Urethrotomy may be performed on horses in a 
standing position, the hind feet being secured with hobbles. 

It is best, however, to operate under anaesthesia with the 
patient in lateral or dorsal recumbency, either on the operat- 
ing table or cast, being careful to secure as gently as possi- 
ble, having first emptied the bladder if practicable, since 
rupture of an overdistended viscus may readily occur during 
violent struggles by the animal. 

The point of operation will depend upon the location of 
the calculus or other obstacle. If it is found in the pelvic 
portion of the urethra or in the bladder, the operation is 
made at the ischial notch. Fig. lo. First the penis is drawn 
out from the prepuce and the catheter introduced into the 
urethra and pushed upward until it has passed the ischial 
notch. After disinfection of the skin, render it tense and 
make a 5 cm. long incision on the median line at the ischial 
arch through the skin, bulbo-cavernosus muscle, spongy 
portion of the urethra, and t|ie urethral mucous membrane 



URETHROTOMY. LITHOTOMY. 



115 



down to the catheter, Fig. 11 , k. In order to prevent infil- 
tration of urine after the operation, special care is to be 
taken to make the lower end of the wound slanting in such 
a manner that the deeper margin is higher than the 
superficial. 

After the catheter has been drawn back away from the 
ischial arch, introduce the lithotomy forceps into the urethra 
or bladder, grasp the stone and draw it outward in its natural 
direction. The grasping of the stone with the forceps is 




Fig. 10. 

Urethrotomy at the ischial notch. 

materially aided by means of the left hand introduced into 
the rectum. One must avoid grasping, along with the 
stone, the mucous membrane of the bladder. Partial filling 
of the bladder with a tepid aseptic solution will aid in grasp- 
ing the calculus and in avoiding the implication of the 
bladder walls. By careful rotary movement and pushing 
the forceps backward and forward the operator can deter- 
mine before traction is exerted if the forceps can be with- 



ii6 



URETHROTOMY. LITHOTOMY. 



drawn easily and without much resistance through the neck 
of the bladder. 

If the stone is so large that it cannot pass the neck of the 
bladder lithotripsy may be performed. This operation re- 
quires time and patience, since as a rule it is not possible to 
encompass the entire calculus with the forceps. That is, 
the narrowness of the neck of the bladder prevents the 
sufficiently wide opening of the forceps. The stone con- 




Fig. 11. 

Urethrotomy (Hfe size), h, skin; a, retractor penis muscle; 
b, bulbo- cavernous muscle ; c, spongy urethra ; n, urethra ; 
k, catheter. 

sequently must be gradually broken off at its periphery and 
the individual pieces of calculus removed. The character 
of the surface of the stone has an evident bearing upon the 
practicability of lithotripsy. 

The surgical dilation of the pelvic urethra with the 
lithotome is usually far more practical than the crushing of 
the stone. Introduce the instrument and divide the urethra 
upward on the median line as the instrument is withdrawn. 



AMPUTATION OF THE PENIS. 1 17 

In order to prevent injur}^ to the rectum it should be emptied 
of feces before the operation is undertaken. After the re- 
moval of the stone, the operator may push the catheter 
again over the ischial arch and unite the lips of the wound 
in the urethral mucous membrane by means of intestinal 
sutures. Flush the bladder and urethra by means of a 
warm, 3 per cent, boric acid solution injected through the 
catheter and then withdraw the latter. Finally, suture 
the skin wound and insert a drainage tube or iodoform gauze 
in the lower angle. 

Or the whole wound may be left entirely open and dressed 
daily with antiseptics. In case the pelvic urethra has been 
divided the suturing of the external wound is of questionable 
utility. 

(For student practice on an anaesthetized horse, intro- 
duce a stone into the bladder through the urethral wound 
and practice grasping and removing it with the lithotomy 
forceps. ) 



25. AMPUTATION OF THE PENIS. 
Plate XIX and Fig. 12. 

Instruments. Scalpel, elastic ligature, strong silk 
suture, strong piece of tape i m. long, artery and compres- 
sion forceps. 

Technic. The operation is carried out on the recumbent 
animal under local or general anaesthesia, the upper hind 
foot being drawn backward or upward or otherwise so fixed 
as to not obstruct the field of operation. The point of 
operation is determined by the character of the disease and 
the object to be attained. It may be made at any point 
from the glans penis to the attachment of the corpus caver- 
nosum to the ischium. If possible amputate in front of the 
preputial ring. . 








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AMPUTATION OF THE PENIS. 



121 



After the penis has been drawn out, and the preputial 
region carefully cleansed and disinfected, an assistant grasps 
the organ just behind the preputial ring and holds it firmly. 
A catheter is then introduced into the urethra and pushed 
upwards beyond the point where it is designed to amputate 
the organ and a temporary elastic ligature, T, is then applied 




Fig. 12. 

Amputation of the penis, showing needle inserted for a suture. 
V, Dorsal vessels of penis ; A, Fibrous tunic of the corpus 
cavernosum ; S, Skin ; CC, Corpus cavernosum ; CS, Corpus 
spongiosuuKof urethra ; U, Urethra. 

above the assistant's hand around the penis, or a piece of 
tape is looped around it above the hand and is made to serve 
both as a tourniquet and as a means for holding the penis. 
Or the penis may be grasped in front of the ligature with 
double tenaculum forceps and held. 



122 AMPUTATION OF THE PENIS. 

Apply a small cord just behind the glaiis penis, L, Fig. 
I, P ate XIX, and then make a triangular incision on the 
ventral surface of the organ about 4 cm. long by 3 cm. 
wide, the base of the triangle being forward as shown in 
Fig. I ; carry this incision through the skin, S, the corpus 
spongiosum, CS, and along the corpus cavernosum, CC, 
down to the urethra, U. Dissect away the tissues in the 
triangular area without opening or wounding the urethra 
and when this has been completed make a longitudinal 
incision from near the apex of the triangle to its base 
through the urethral walls to the catheter. Beginning at 
the apex of the triangular wound insert a series of inter- 
rupted sutures as shown in Fig. 2, Plate XIX in such a 
manner that they pass through the urethral wall and the 
skin so that when tied the wounded surfaces are completely 
hidden and the urethral mucous membrane is brought into 
apposition with the integument. Continue these sutures 
down to the base of the triangle after which remove the 
catheter and excise the organ by a cut extending in a slightly 
oblique direction from below upwards and forwards. Take 
a straight needle armed with the silk suture and passing 
it through the margin of the urethral wound, the adjacent 
fibrous capsule of the corpus cavernosum and across but 
not through the erectile tissue, insert it again into the 
superior portion of the fibrous capsule and carry it out 
through the adjacent dorsal vessels and the skin as shown 
in Fig. 12, and, bringing the ends of the sutures together, 
tie in such a way that the urethral mucous membrane and 
the margin of the skin are brought into immediate contact 
and the blood vessels securely closed in such a manner as to 
guard against hemorrhage. By this plan when the sutures 
are tied, the cut borders of the fibrous envelope are brought 
together over the erectile tissue, thus preventing hemor- 
rhage from that tissue also. Insert as many sutures as 
may be required to completely and securely close the wound 



VA GINAL O I A RIO TOM Y IN THE MARE. j 2 3 

and finally leave every part wholly covered with epithelium. 
By this plan it is hoped to avoid stricture of the urethra in 
the process of healing. Remove the tourniquet and release 
the patient. 



26. VAGINAL OVARIOTOMY IN THE MARE. 
Figs. 13-14. 

Objects. The alleviation of vice when related to ovarian 
irritation or disease. 

Instruments. Colin's scalpel, ratchet ecrasure, 55 cm. 
long, vaginal tensor. 

Preparation of patient. It is highly important that 
the animal should be kept on a scant laxative diet for at 
least 24 hours and preferably longer prior to the operation, 
so that the alimentary canal shall be somewhat empty and 
thus decrease the intra-abdominal tension and relieve 
the operator from much annoyance due to the pressure of 
the viscera. 

Technic. The vagina of the mare is unique in its 
physiological behavior. Under venereal excitement or the 
introduction of the operator's hand or of tepid water the 
organ has the power of ' ' ballooning ' ' or dilating to a degree 
not so marked in other animals ; the vaginal walls become 
erected, hard, and stand apart from each other, filling the 
pelvic cavity, resting firmly against the pelvic bones 
and ligaments at every part except at the points where 
the bladder and rectum intervene and these organs are 
pressed out flat and occupy a minimum amount of space. 
In the quiescent state the vaginal walls are in contact and 
from the perinaeum forward to within about 10 cm. of the 
uterine os, the vulva and vagina are connected above with 
the rectum by the pelvic connective tissue, while anterior 
to this point the vagina is covered by peritoneum, and it is 



124 



VAGINAL OVARIOTOMY IN THE MARE. 



in this area that the incision needs be made in the operation. 
The ballooning of the vagina profoundly alters the relation 
of this operative area, and changes it from the horizontal 
in the quiescent organ to the perpendicular in the ballooned 
condition. These variations permit of two methods of 
operating : I. On the ballooned organ without anaesthesia 
and with the animal confined in the standing position. II. 
On the quiescent organ in the recumbent position under 
anaesthesia : 

I. Without anaesthesia. Secure in the stocks with the 
head elevated, a rope over the back to prevent rearing. 





Fig. 13. 

Special spraying ecraser, 55 cm. long. 




Fig. 14. 

CoUn's scalpel. 

straps beneath the body to prevent lying down, straps or 
ropes before and behind the animal to prevent backward 
and forward movements, all four feet pinioned to the floor, 
and the tail firmly secured and stretched to a beam above. 
Apply a bandage to the tail extending for a distance of 12 
to 15 inches from the base of the tail in order to secure the 
tail hairs out of the way of the operator. 

With soap, water and brush cleanse the tail, perineum and 
vulva thoroughly, being especially careful to remove all 



VAGINAL OVARIOTOMY IN THE MARE. 125 

detachable masses of sebum ; 50 per cent, alcohol may be 
used sparingly to aid in removing this. Too free a use of 
alcohol excoriates the delicate skin. Cleanse the clitoris 
carefully. Follow the washing with a free application of 
i: 1000 aqueous sublimate solution to the external parts and 
for a short distance inside the vulvar lips and to the clitoris. 
Do not introduce irritant disinfectants into the healthy 
vagina nor deeply into the vulva as it may cause severe 
straining during and subsequent to the operation and by in- 
juring the vulvo-vaginal mucosa favor subsequent infection 
of the vaginal wound. 

Wash away the sublimate solution with a tepid 0.6 per 
cent, soda bicarbonate solution, and fill the vulvo-vaginal 
canal with the same. After thorough disinfection of the 
hands and arms remove the disinfectants by washing in 
sterile soda solution, which at the same time renders the 
hand unctuous and readily introduced through the vulva. 
x\rmed with the guarded sterilized scalpel, Fig. 14, intro- 
duce the right hand into the vagina promptly and when it 
is well " ballooned " unsheath the knife and placing it just 
above the os uteri parallel to the long axis of the uterus and 
a few mm. to the right or left of the median line in order to 
avoid a loose fold of mucous membrane generally existing 
there, the blade being held vertical, that is the cutting sur- 
face parallel to the longitudinal muscular fibers of the 
vagina, and guarding the possible extent of its introduction 
with the thumb and fingers, push it directly forward in a 
straight line with a quick thrust through vaginal mucosa, 
the muscular walls and the peritoneum, until the disap- 
pearance of resistance indicates that the latter has been 
penetrated. This is the most critical step in the operation. 
If the hand is introduced into the vagina immediately 
after the injection of the sterile saHne solution the vagina 
will generally be found '' ballooned " or will quickly become 
inflated under manual movements. If the solution is thrown 



126 J'AGINAL OVARIOTOMY IN THE MARE. 

out the vagina may collapse and closely invest the hand, in 
which case more of the liquid should be injected when it 
will again dilate. If the hand is introduced without the 
knife, withdrawn and then introduced with it, it will be 
frequently found that the vagina has collapsed and needs a 
second filling with the fluid. Patience until dilation is 
accomplished and promptness to act when attained are prime 
requisites to success. 

The knife should be pushed through the vagina quickly 
making a clean wound the width of the blade, when the 
latter is to be withdrawn and laid aside. It should be re- 
membered that in this "ballooned" state, the anterior 
wall of the vagina is but 2 or 3 mm. thick and easily pene- 
trated. Introduce the hand again, push one finger into the 
incision, then a second and third, and eventually holding 
all the fingers in the form of a cone push the entire hand 
into the peritoneal cavity. Immediately below the incision 
and continuous with the tissues involved in the wound lies 
the uterus with a transverse diameter of 4 to 6 cm. With 
the palm of the hand downward, trace the uterus forward a 
distance of 15 to 18 cm., where it ends abruptly in two 
cornua of about the same size as the body, which are given 
off horizontally at almost right angles. Trace these to the 
right and left for a distance of 14 or 15 cm., where they 
end obtusely, and 3 or 4 cm. beyond this in a direct line, 
resting upon the anterior border of the broad ligament is the 
dense oval ovary varying in size from 2.5 to 7 cm. in 
diameter. 

Prepare the ecraseur for use by withdrawing the chain 
until the loop is of barely sufficient size to admit of its being 
readily slipped over the ovary. Grasp this loop and the end 
of the ecraseur tube in the hand, carry the instrument 
to the ovary and drop the loop over it from above. Pass 
some of the fingers beneath the ovary and push it up 
through the chain loop and grasp it there with the thumb 



VA GINAL O I A RIO TOM} ' IN THE MARE. 1 2 7 

and index finger. Holding the ovary with one hand tighten 
the chain quickly with the other, examine to make sure 
that a loop of intestine is not caught, draw the ovary well 
through and get a large portion of the oviduct, and crush 
off promptly, holding to the gland until carried out through 
the vulva. Remove the other ovary in the same way. 
Generally it is most convenient to remove the left ovary 
with the right hand and vice- versa but each may be re- 
moved with either hand. Wash away any blood from the 
external parts, apply sublimate solution freely to the vulva, 
perineum and tail. Keep the patient quiet for five or six 
daj'S, and feed lightly on a laxative diet. 

II. In operating under anaesthesia the animal should be 
cast or confined upon the operating table in lateral re- 
cumbency preferably with the posterior part of the body 
somewhat higher than the anterior so as to avoid visceral 
pressure in the pelvic cavity. Place the animal under com- 
plete anaesthesia. Prepare the parts in the same manner 
as already described. Carry the knife into the vagina in the 
manner previousl}^ described and render the roof of that 
organ tense by pushing the os uteri downward and forward 
with the hand or by means of a vaginal tensor or speculum. 
It is important that the vagina be held well down toward 
the floor of the pelvis so as to carry it away from the rectum, 
posterior aorta and iliac arteries while the incision is being 
made. The incision is now to be made just above and be- 
hind and a trifle to one side of the os uteri in essentially the 
same manner as under I, except that when the vaginal 
tensor is used Jthe cut is made upward and backward instead 
of directly forward. The remainder of the operation is 
identical with what we have described under I. Under 
anaesthesia the vagina is flaccid and can not be made to 
" balloon." 



128 VAGINAL OVARIOTOMY IN THE MARE. 

DANGERS. 

Wounding of the rectum is scarcely possible under the 
first method if care is taken not to attempt the incision until 
the vagina is well "ballooned," and then making the stab 
wound directly forward. If made upwards when the organ 
is so erected the accident is highly probable, and with the 
undilated vagina where it is necessary to cut upwards the 
danger is ever present. Its prevention demands that in the 
first method, the operator await the complete " ballooning "^ 
and then make his incision as directed. In the second 
method, the accident is to be prevented by being careful to- 
push the vagina down away from the rectum and hold it 
away while the incision is being made. If the wound in the 
rectum passes through the pelvic connective tissue behind 
the peritoneum it is of little consequence, but the operation 
should be abandoned ; if the bowel is opened into the 
peritoneal cavity the accident is generally fatal. 

Wounding of the iliac arteries, which generally pro- 
duces prompt death from hemorrhage, results from the in- 
cision being made upwards instead of forwards when the 
vagina is " ballooned " or from a failure to hold the roof of 
the vagina down and away from the part while making the 
incision in the flaccid organ as is the case with the recumbent 
animal under anaesthesia. It is most likely to occur with 
timid operators who become nervous, especially when the 
vagina does not " balloon " promptly or the mare is not well 
secured. The accident is wholly unnecessary if the operator 
will await the " ballooning " in the first operation while by 
the second method it is prevented by proper care in holding 
the vagina downward and forward during the incision. 
When it has occurred it is generally beyond remedy though 
in some cases the prompt intravenous injection of adrenaline 
chloride may stay the hemorrhage and save life of the 
patient. 



\ 

% 



VAGINAL OVARIOTOMY IN THE MARE. 129 

^A^ounding of the uterus ma}^ occur when the incision is 
directed downward and may greatly embarrass the operator 
and confuse him by passing the hand through the incision 
into the uterine cavity. It is to be avoided in the first 
operation (without anaesthesia) by carefully directing the 
incision straight forwards. When the accident occurs it is 
of little consequence beyond the embarrassment and may be 
overcome by again dilating the vagina with fresh injections 
of the soda solution and making a new incision, or if pre- 
ferred the first cut may be corrected by placing an index 
finger against the peritoneum at the upper part of the 
wound, and with a sudden and vigorous thrust break 
through into the peritoneal cavity, or the error may be 
corrected by again using the scalpel and directing the in- 
cision properly. If it is attempted to rupture the peritoneum 
with the finger it must be done by a sharp thrust since 
otherwise a large section of the membrane will be pushed 
away from the subjacent tissues. 

Incomplete penetration of the vaginal wall is liable to 
occur if the scalpel is dull or the vagina imperfectly " bal- 
looned " and flaccid, or if the operator is unduly timid. It 
is best prevented by avoiding the causes as related, and 
once it has occurred it is generally best to again "balloon " 
the organ in the operation without anaesthesia and make a 
new incision either to the right or left of the first. It may 
be overcome also by thrusting the index finger through the 
peritoneum as described in the preceding paragraph or 
completing the cut with the scalpel. 

The mistaking of a ball of feces for the ovary has oc- 
curred to inexperienced operators and the fatal error of re- 
moving the portion of the rectum surrounding the fecal pellet 
committed. The blunder is uncalled for ; the fecal ball is 
movable in the bowel, the intestine is far more massive 
than the broad ligament, and the ovary is to be definitely 
identified by its being lodged in the broad ligament just 
9 



1 30 r.-^ GIN A L O I 'A RIO TOM J ' IN THE CO W. 

beyond the end of the cornua, which is continuous with the 
uterus. If, therefore, one traces the uterus forward to the 
cornua, thence along each of these to their extremities and 
along the borders of the broad ligament to the ovary, as 
above directed, the error will not occur. 

The incision may be made too low and pass beneath 
the broad ligament. It is to be avoided by being careful to 
keep close to the median line and above the os uteri. If it 
occurs the operation may be completed from beneath with- 
out very great difficulty only that the ovary now lies above 
the hand and must be drawn down from on top the broad 
ligament in order to fix the ecraseur upon it. 

Infection constitutes always the most serious danger and 
is to be avoided by properly securing the animal, by the 
avoidance of irritant antiseptics in the vagina, by rigid anti- 
sepsis at every stage, and by carrying out the mechanical 
parts of the operation deliberately, vigorously and neatly. 
If infection should occur it will generally take the form of 
pelvic cellulitis with abscesses and rectal stricture. Enemas 
of a normal salt or soda solution affords the surest relief of 
the stricture and impaction in front of it. The abscesses 
must be watched and opened early into the vagina or rec- 
tum, and the case treated internalh' and locally according 
to general surgical principles. 



27. VAGINAL OVARIOTOMY IN THE COW. 

Objects. Increasing the fat- or milk-producing qualities 
and the cure of nymphomania or other ovarian disease. 

Instruments. Colin's scalpel, vaginal dilator. Miles' 
spaying shears, spaying ecraseur. 

Technic. Confine the cow in the standing position in 
the stocks, secure the head firmly and pass two boards be- 
neath the abdomen and sternum to prevent lying down, and 
a rope over the middle of the back to prevent arching of 
the spinal column and straining. 



VAGINAL OVARIOTOMY IN THE COW. 131 

Wash and disinfect the tail and the perineum and flush 
out the vagina with a 0.5 per cent, sohition of carbolic acid 
or lysol at a temperature of about 100° F. Insert the 
vaginal dilator with one hand and push the prolongation at 
the anterior end into the os uteri. With the other hand 
elevate the handle of the dilator and depress and push for- 
ward the uterus, thus rendering the roof of the vagina tense 
and pushing it downward away from the rectum Carry 
the scalpel into the vagina with the right hand and resting 
it in the oval of the dilator make an incision through the 
roof of the vagina, beginning at a point 8 to 10 cm. posterior 
to the OS uteri and extending backward on the median line 
for a distance of 2 or 3 cm. Be careful to make the incision 
entirely through the mucosa, muscle and peritoneum at the 
first cut, since any failure to complete it tends to cause the 
peritoneum to separate from the muscular coat and form a 
pocket between them, while the serous membrane being 
very elastic renders it difficult to complete the incision. 
Introduce two fingers through the incision, and reaching 
over the side of the vagina to the right or the left, the right 
or left ovary respectively is recognized lying immediately 
against the lower part of the vagina, just at the anterior 
border of the pubis, in a mass consisting of the cord-like 
Fallopian tube and the fimbriae of its pavilion. The ovary 
may be distinguished as a firm oval mass 2 to 4 cm. in length 
and I to 2 cm. in its lesser diameter attached to the broad 
ligament. If not promptly recognized by the sense of touch, 
trace the vagina and uterus forwards with the fingers from 
the vaginal incision to the cornua and follow them as they 
bend forward^ and downward, and then backward and up- 
ward to the oviducts, until the ovary is reached where it is 
attached to the broad ligament, just beyond the fimbriated 
end. 

Grasp the ovary between the fingers and draw it through 
the incision into the vagina. Introduce the scissors or 
emasculator with the other hand, and when the ovary is 



132 



VAGINAL OlARIOTOMY IN THE COW. 



reached open them barely sufficient to admit the ovarian 
attachments between the blades and cut the gland away 
along with a portion of the broad ligament. Or introduce 
the ecraseur and drawing the ovary through the loop of the 
chain and holding it securely until the instrument is 
tightened, crush it off in this way. 

It is essential that plenty of the broad ligament and ovi- 
duct be excised with the ovary to insure the entire removal 
of the latter, because the accidental leaving of the smallest 
particle of ovarian tissue will cause a development of this 
into abnormally large cystic ovisacs, and will tend to in- 
crease instead of decrease nymphomania. Should the 
animal be pregnant the ovary on the gravid side is dragged 
downward and forward out of reach of the operator's 
fingers, and if it is desired to complete the operation it may 
be necessary to enlarge the vaginal wound and introduce 
the entire hand, when the ovary can be reached and re- 
moved. Generally no after care is necessary. 

The Dangers are similar to those of the mare. The 
iliac arteries may be wounded in the same manner as in the 
mare and is preventable by being careful to push the vaginal 
roof well downwards awa}^ from the rectum and sacrum. 
In rare instances fatal hemorrhage follows the cutting off 
of the ovaries with the scissors especially in cows sterile be- 
cause of diseased ovaries accompanied by a want of tone. 
For this reason it is safer in cows sterile from diseased 
ovaries to use the ecraseur but even this instrument is not 
wholly proof against hemorrhage and fatalities have been 
rarely recorded after its use so that some veterinarians have 
advised ligation of the arteries instead, but this is a complex 
process which requires much time for its accomplishment. 
Another danger appears in the presence of the rumen, the 
supero-posterior portion of which when filled with food 
projects into the pelvic cavity and if the cut is directed for- 
wards a stab wound readily penetrates its walls with fatal 
results. Make the cut upwards and backwards. 



OVARIOTOMY IN THE COW BY THE FLANK. 133 
28. OVARIOTOMY IN THE COW BY THE FLANK. 

Instruments. Clipping shears, convex scalpel, spaying 
shears, or ecraseur, heavy needle and thread. 

Uses. Same as the preceding, applicable to heifers or to 
cows in which the vulva is too small to admit the operator's 
hand or in case of diseased vagina or uterus. 

The animal may be secured as in the preceding or con- 
fined in lateral recumbency with the hind legs extended 
backward and the anterior limbs forward. To accomplish 
this loop a rope about the two fore feet, another about the 
two hind feet, and drawing upon these, cast the animal and 
secure it in recumbency with the legs extended and body 
stretched by fastening the ropes to two strong posts about 
8 to 10 m. apart. The operation may be performed in either 
flank. 

Clip the hair from the upper part of the flank, disinfect 
an area 15 to 25 cm. square and make an incision about 12 
cm. long beginning at a point equi-distant from the anterior 
tuberosity of the ilium, the ends of the transverse processes 
of the lumbar vertebrae and the last rib and extend it down- 
wards perpendicularly severing the skin and subcutaneous 
muscle. Divide the external oblique muscle in the direction 
of its fibres by means of the scalpel handle or the fingers 
and repeat the process upon the internal oblique after which 
puncture the peritoneum with the scalpel. Some operators 
cut directly through the entire abdominal wall at a single 
stroke, but this comes to the operator only by experience. 

Force one hand through the opening into the peritoneal 
cavity and search for the ovaries at the same point and by 
the same method as in the preceding operation, that is, 
locate the uterus within the pelvic cavity, between the 
rectum and bladder and trace it, the cornu, and broad 
ligament to the ovary. The uppermost ovary can be drawn 
out through the wound and cut off with the scissors or 
ecraseur ; the lower one must be held with one hand and 



1 34 O VARIO T03f} ' IN THE BITCH. 

the instrument introduced along the arm and when the 
ovary is reached, apply the scissors or ecraseur and cut or 
crush it off. The beginner must always remember that the 
positive means for identifying the ovaries is by tracing the 
uterus from the vagina along its cornua to the oviduct and 
thence to the organ in the broad ligament. Cleanse the 
wound and close the skin incision with continuous sutures. 



29. OVARIOTOMY IN THE BITCH BY THE FLANK. 
Plate XX. 

Instruments. Spaying knife, suture material. 

Techic. Confine the animal in lateral recumbency, 
preferably upon the right side for a right handed operator, 
the head somewhat depressed, the limbs extended and the 
body well stretched. Clip, shave and disinfect a sufficient 
area in the exposed flank at a point just anterior to and be- 
neath the external angle of the ilium. With one hand grasp 
the skin fold of the flank and render the skin of the region 
tense, while with the other holding the spaying knife like a 
pen make at first a drawing incision from below upward 
about 2 to 3 cm. long, ending above at a point slightly be- 
low the external angle of the ilium, the incision extending 
through the skin and subcutaneous tissues ; without remov- 
ing the knife from the wound elevate the handle and with 
a quick thrust make a stab wound extending through the 
external and internal oblique muscles and peritoneum at a 
single cut. The operator can determine when the peritoneal 
cavit}^ has been entered by the disappearance of resistance. 

Introduce an index finger into the peritoneal cavity, and 
as soon as this has been entered follow directly along the 
peritoneum upward and backward toward the angle of the 
ilium where the uterine cornua lie covered over by the 
broad ligament. The internal generative organs of the 



\ 

% 



OVARIOTOMY IN THE BITCH. 135 

bitch are unique among our domesticated animals. The 
uterus, U, Plate XX, is small and physiologically unim- 
portant, the cornua, RUC and LUC, are ample in size and 
constitute physiologically the uterus. The distance from 
the cornual extremity, LUC, to the ovary, O, which is 
occupied by the Fallopian tube is very brief so that the 
cornua and ovary are well nigh in contact. The ovary, 
O, O, is very small, smooth and completely hidden in the 
pavilion which here constitutes a sac having a very small 
longitudinal opening of 2 to 5 mm. The most remarkable 
feature of the apparatus from a surgical standpoint is the 
great development of the broad ligament which is broader 
than the distance from the lumbar region to the abdominal 
floor, while the uterus and uterine cornua are stretched 
between the vagina, V, and the ovary, O, so that they are 
suspended in the sub-lumbar region resulting in a double 
fold of the broad ligament hanging down like a curtain be- 
tween the parietal peritoneum and the uterus and cornua 
on either side. The broad ligament of the bitch is conse- 
quently suspended at one point from the sub-lumbar region, 
at the other from the uterus, so that instead of that organ 
being suspended by the ligament the relation is reversed 
and the ligament is suspended from the uterus, or rather 
uterine cornua. 

In Plate XX the right broad ligament, BL', is laid out 
upon the side exposing the right uterine cornu, RUC, while 
on the left side the ligament is divided at about its center 
and the posterior portion, BL', is laid out on the flank,, 
while the anterior, BL, is left in its normal position con- 
cealing a portion of the cornu, LUC. Unlike our other 
domesticated animals, the broad ligament is heavily loaded 
with fat which gives it an appearance very similar to the 
omentum, but the net-work is far less conspicuous or want- 
ing, the omentum also extends back into this region so that 
the two are in contact. 



Plate XX. 

Ovariotomy in the Bitch. 

Abdomen of a nou-pregnant bitch lying on 
the back with the abdominal floor removed and 
the omentum pushed away. TT, the two pos- 
terior teats ; B, bladder ; V, vagina ; U, uterus ; 
LUC, LUC, left uterine cornua with a portion 
of its broad ligament, BL. lying across it ; RUC, 
right uterine cornua with its broad ligament, 
BL^, turned outwards exposing the full length 
of the cornua. On the left side the ligament is 
divided so that the anterior half rests in its nor- 
mal position while the posterior half, BL'', is 
turned back. 0,0, ovaries ; R, rectum ; K, left 
kidney ; AA, a line indicating the level of the 
external tuberosities of the ilia. 




--Ab.^.. 1^ I 



^rji 



::iL^_^ 




OVARIOTOMY IN THE BITCH. 139 

The ovary being indistinct and hidden is difficult to iden- 
tify directly, and the cornua being covered over by the 
duplicature of the broad ligament is not readily reached, 
so that the finger generally comes in contact first with the 
broad ligament of the uppermost cornu hanging loose in 
the peritoneal cavity : engage this between the end of the 
finger and the abdominal wall and draw it out through the 
wound, grasp it and continue drawing upon the folds of the 
ligament, especially upon the median or under-most portion 
until the naked cornu appears through the opening, seize 
it and draw out the anterior portion until the ovary follows, 
then grasp the latter with the thumb and index finger of 
one hand and the ovarian ligament with the same members 
of the other and tear the ligament through between them 
by linear tension. Extend the tear through the broad liga- 
ment as high toward its lumbar attachment as is convenient 
and backward to the neighborhood of the uterine bifurca- 
tion. Draw upon the exposed cornu until the point of bi- 
furcation appears, when the other branch is to be grasped 
and drawn out through the opening. In young puppies the 
securing of the second cornu is very difficult and requires 
great care to prevent the rupture of the first. The object 
may be facilitated by pressing the upper flank of the bitch 
downward, thereby greatly diminishing the transverse 
diameter of the abdomen. 

The succeeding operation (30) avoids this difficulty in a 
large measure. Should the distal cornu be ruptured and 
with its ovary drop away from the operator, it becomes nec- 
essary to turn the animal over and make a second incision 
on the opposite side, somewhat further forward. When the 
second cornua has been secured draw it out as far as prac- 
ticable and holding it tense insert an index finger along it 
until the ovary is reached, which is recognized by its slightly 
greater size and density succeeding the brief neck represent- 
ing the Fallopian tube between the end of the cornu and 



I40 OVARIOTOMY IN THE BITCH. 

ovary, while beyond it can be felt the ovarian ligament. 
Engage the ligament between the end of the index finger 
and the abdominal wall, and with a firm and vigorous move- 
ment, using the finger end and nail as a curette, rupture 
the ovarian ligament by drawing the finger toward the in- 
cision, and with the aid of tension upon the cornu draw the 
ovary out through the abdominal incision and divide the 
broad ligament as before. Remove the cornua with the 
attached ovaries by rupturing them transversely near the 
bifurcation by means of linear tension. 

If the bitch be pregnant and especially if far advanced 
the uterine cornua will lie upon the abdominal floor, much 
enlarged and very much more flaccid than the nongravid 
uterus and feeling very much like intestines. The change 
in the position of the uterus has caused the unfolding of the 
duplicature of the broad ligament so that it no longer covers 
the cornu. In such cases the operation is performed in the 
same way except that rupturing the blood vessels by linear 
tension does not insure against hemorrhage and it is neces- 
sary to ligate the ovarian and uterine arteries with catgut 
or silk. In cases of pregnancy the entire cornua should be 
drawn out and a strong ligature placed around the uterus 
or vagina, and the ovaries, uterine cornua and their con- 
tents be removed en masse. Release the upper posterior 
limb and close the cutaneous wound by a continuous suture. 

Dangers. Rupture of the uterine cornu alluded to above. 
It is always to be remembered that the leaving of one 
ovary in position even though the other gland with the two 
cornua and uterus are removed, induces intense oestrum 
and renders the animal if anything more disagreeable than 
before the operation. 

The ureter may be mistaken for the cornu but is smaller, 
is closely attached to the abdominal walls, and does not 
have the broad ligament with its large deposit of fat. The 
kidney is far larger than the ovary, more exposed, and 
located more anteriorly. 



OVARIOTOMY IN THE BITCH. 



141 



The iliac arteries are at times caught and ruptured by 
the finger but the blunder is uncalled for except through 
nervousness of the operator. 

Instances of puncturing the bladder in making the in- 
cision have been reported. If the bitch has been led out 
and caused to urinate prior to operating, the accident is 
made practically impossible. 



30. OVARIOTOMY IN THE BITCH BY THE LINEA ALBA. 
Plate XX. 

Instruments. Same as in the preceding. 

Technic. Confine in the dorsal position with the head 
sharply declined. Shave and disinfect an area on the median 
line about 6 cm. square extending forward from the pubic 
brim. Make an incision on the median line about 4 cm. 
long beginning just in front of the pubic brim and extend- 
ing forward cutting entirely through the skin, the linea 
alba and peritoneum. Insert an index finger and identify 
the uterus or broad ligament by its location and form. 
The finger usually comes in contact first with the urinary 
bladder which may more or less obstruct the passage to the 
uterus according to its degree of distension. When empty 
as shown at B, it offers practically no obstruction. When 
very much distended it may be evacuated by gentle pressure 
with the fingers. The operator should be careful not to 
draw the bladder out through the incision as its replace- 
ment may prove difficult and its puncture with a hypo- 
dermic needle or an enlargement of the abdominal incision 
may be necessary in order to bring about its return. Push 
the bladder aside if necessary and just above it and below the 
rectum the uterus should be readily distinguished and either 
it or the broad ligament caught by the finger and brought 
out through the incision after which the operation proceeds 



142 OVARIOTOMY IN THE CAT. 

in the same manner as by the flank method. By passing an 
index finger forward to reach the lower surface of the rec- 
tum in front of the uterus and then drawing it backwards 
the finger passes between the former and the cornua and 
the latter are picked up. It has a distinct advantage over 
the flank method in that in puppies there is not so much 
difficulty in bringing out the ovaries, nor the danger of the 
rupture of the cornua and the ovary being retained. 

By the use of retractors in the abdominal incision the 
operator is enabled to see the uterus in position and grasp it 
by means of forceps, obviating the necessity for introducing 
the finger into the peritoneal cavity. 

The sutures must extend entirely through the abdominal 
wall and be carefully placed in order to prevent hernia. 
Interrupted sutures are preferable. If the operation has 
been properly performed no bandage is necessary and the 
patient will not disturb the sutures. If asepsis has not been 
strictly followed infection may occur and the consequent 
irritation cause the patient to tear the sutures out, which 
may lead to protrusion of the intestines or other abdominal 
'viscera. If the sutures do not include the deeper layers of 
the abdominal wall hernia is liable to occur and require a 
second operation. 



31. OVARIOTOMY IN THE CAT. 

Instruments. Same as for the bitch. 

Technic. The cat may be spayed by either the flank 
method or through the linea alba. The point of incision in 
either case is the same as in the bitch but owing to the 
smaller size of the animal it is necessary to make the wound 
quite small. The abundance of fur renders it essential 
that an ample area be shaved and the surrounding hair be 
saturated with a disinfectant and carefully brushed away 



CASTRATION OF CRYPTORCHID HORSES. 



^43 



from the operative area. The cat being more subject to 
infection than the bitch the aseptic precautions must be of 
the strictest possible character. The operative area must 
be thoroughly disinfected and cleansed and equal care must 
be taken not to introduce irritant disinfectants into the 
wound. A great danger also exists in the tendency of the 
muscle layers of the abdomen to readily become separated by 
pressure from the finger and form a pocket in which wound 
discharges accumulate and constitute a dangerous seat for 
infection. Great care must therefore be taken to make a 
clean incision directly into the peritoneal cavity and to 
avoid separating the peritoneum from the muscles or the 
muscular layers from each other. The uterus and ovaries 
of the cat are naked and far more easily distinguished than 
in the bitch, there being no extra deposit of fat in the broad 
ligament. The sutures are to be applied to the wound in 
the same manner as in the bitch. 



32. CASTRATION OF CRYPTORCHID HORSES. 
Plates XXI and XXIL 

Instruments. Scalpel, emasculator. 

Technic. Confine the animal by casting in the dorsal 
position with the hocks well flexed and both posterior 
limbs completely abducted so as to fully expose the inguinal 
region. Or secure upon the operating table on the side 
opposite to the retained gland and abduct the upper pos- 
terior limb by drawing it upward by means of a pulley. 
Cleanse and disinfect the inguinal region. Anaesthize. 
Make an incision about lo to 12 cm. long through the skin 
and dartos directly over the normal position of the scrotum, 
parallel to the median raphe about 4 or 5 cm. distant from 
it. Insert the two index fingers in the wound, press 
them into the areolar tissue toward the external inguinal 



144 



C ASTRA riON OF CR J PTORCHID HORSES. 



ring and drawing them apart separate the tissues 
sufficiently to permit the entrance of the hand. With the 
fingers held in the shape of a cone bore a passage in the 
areolar tissue through the external abdominal ring and con- 
tinue in a direction approximately toward the external 
angle of the ilium until the aponerosis of the small oblique 
muscle near the crural arch is reached. Unless rectal ex- 
ploration has shown that the testicleis within the abdomen, 
take care in traversing the inguinal space between the ex- 
ternal and internal rings that the gland is not passed hj 
unrecognized (inguinal cryptorchidy) lying in this region- 
covered by peritoneum and the cremasteric fascia. Some- 
times the epididymis has descended to the scrotal regioni 
while the testicle remains within the abdomen, thus result- 
ing in a long, narrow inguinal canal. 

Pass the hand upwards, outwards and forwards along the 
aponeurosis of the small oblique until the crural arch is- 
reached slightly anterior to the crural ring in which the 
pulsating femoral artery can be felt, and palpate at this point 
in the muscular wall for the internal inguinal ring which 
varies greatly in different individuals but usually reveals- 
itself to the fingers as an oblong slit or ring about one inch 
in length covered only by peritoneum. Through this usually 
extends a portion of the gubernaculum testis or of the vas- 
deferens. 

Examing Plate XXI, the peritoneal view of the internali 
ring is shown crossed by the dotted line, V, of the upper or 
right testicle, into w^hich extends a short distance the tail 
of the epididymis. In the lower or left testicle the ring 
has been opened and the gland lies in a position correspond- 
ing to the right and showing the epididymis and vas defer- 
ens lying in the processus vaginalis, P. The surgical rela- 
tion of the parts is further illustrated in Plate XXII, where 
the testicle is completely withdrawn into the peritoneal 
cavity and spread out over the right flank. The processus 



CASTRATION OF CRYPTORCHID HORSES. 145 

vaginalis, P, is outlined by a dotted line into which is in- 
troduced a curved sound, S, along side of which lies the 
gubernaculum, G. The gubernaculum, it will be observed 
is divisible into three sections, a slender one, G, which by 
passing along behind the peritoneum escapes from the 
abdominal cavity at the postero-external commissure of the 
ring to extend to the scrotum. The second portion of this 
organ, G', is much thicker and extends from G to the 
epididymis at E, while the third division, G", extends from 
the epididymis to the testicle. 

In Plate XXII it is shown that the testicle under all ordi- 
nary conditions is inevitably attached through its guber- 
naculum testis to the postero-external commissure of the 
ring and that it has a second definite attachment to the 
seminal bladder through the medium of the vas deferens, V, 
and a third by means of the testicular artery, A. The 
gubernaculum and the vas deferens constitute the essential 
guides in locating and recognizing the testicle. 

By forming a hollow cone with the fingers about the in- 
ternal ring, the vas deferens, epididymis and gubernaculum 
tend to drop out into the processus vaginalis where they 
may be grasped with the fingers without the peritoneum 
having been ruptured. The vas deferens and epididymis 
present characteristics which are unmistakable to the 
trained touch consisting of a small firm cord (vas deferens) 
or a small mass of fine threads (tail of epididymis) which 
roll freely between the thumb and finger and give a sensa- 
tion which is unlike that produced by any other tissue in. 
the body. 

Grasp the part firmly and tearing through the peritoneum 
seize the vas deferens and carefully draw it out through the 
external wound. (In teaching cryptorchid castration to 
the beginner we make our opening down to the internal 
ring and grasp the vas deferens between the thumb and 
finger without penetrating the peritioneal cavity and then 
10 



Plate XXL 

Castration of Cryptorchid Horse. 

Urino genital apparatus of 24 hr. colt. T, T, 
testicle ; A, testicular artery ; G, gubernaculum 
testis ; V, V, vas deferens ; B, urinary bladder ; 
UA, umbilical arteries retracted within abdomen ; 
P, processus vaginalis ; UV, umbilical vein. 



CASTRATION OF CRYPTORCHID HORSES. 149 

passing a pair of long uterine dressing forceps along the 
hand, fasten them upon the vas deferens. The student 
then completes the operation, using the forceps as a guide. 
He thus learns the relations and character of the parts 
and recognizes the internal ring with the peritoneum still 
stretched across it, intact.) 

In case the vas deferens can not be felt before rupturing the 
peritoneum, it may be broken through with the index finger 
and inserting the finger into the cavity, the gubernaculum 
is found attached to the postero-external border of the ring, 
and but a short distance therefrom the finger comes in con- 
tact with the vas deferens or with the tail of the epididymis 
where the gubernaculum crosses it at E, in Plate XXII. 
Having reached the vas deferens the operation is proceeded 
with as above. Thus far the operator has not concerned 
himself with the location of the testicle but relies wholly 
upon the vas deferens or gubernaculum, since when either 
of these is recognized the testicle is virtually within his 
power. 

He thus proceeds upon the basis that he is not toyf^z^the 
testicle for the reason that it is not lost but that it has de- 
finite relations and attachments which permit of certain 
displacements of the organ itself but not of its attachments. 

Having drawn the vas deferens out through the wound 
tension is exerted upon it which tends to cause the testicle 
to follow but sometimes the gland is too large to pass the 
internal ring and the latter needs be dilated by inserting 
an index finger in it or the testicle needs be guided 
through the opening. 

We have described herein one method of castrating a 
cryptorchid horse where the cryptorchidy is due to an arrest 
in the development of the gland and of its descent. There 
are other methods employed which introduce variations at 
each step, many operators making the incision over the 
external ring instead of near the median line. Other 



Plate XXII. 

Castration of Cryptorchid Horse. 

Right inguinal region and testicle of 24 hrs. colt. P, processus 
vaginalis surrounded by a dotted line and containing a curved sound, 
vS ; G, first portion of gubernaculum testis ; G^ second portion of gub- 
ernaculum testis extending to the epididymis, E ; E, epididymis ; 
G^^ gubernaculum extending from epididymis (globus minor) to the 
testicle ; T, testicle ; A, testicular artery ; V, V, vasa deferentia ; B, 
urinary bladder ; UA, umbilical arteries. 






CASTRATION OF CRYPTORCHID HORSES. 153 

Operators avoid opening the internal ring and penetrate the 
peritoneal cavity somewhat in front of and above the ring 
through the small oblique muscle. When one plan has 
been learned the variations are easily applied. 

There are other causes of cryptorchidy which in rare cases 
require a different procedure in order to extract the gland 
varying with individual cases but the essentials for the 
tracing and recognition of the testicle are the same. 

Prior to attempting the operation it is well to make a 
rectal exploration and determine as far as may be the loca- 
tion of the testicle, whether it be on the right or left side, 
and its character, should it be in any way pathologic. 

After the testicle is brought to the surface it may be re- 
moved with the emasculator or by such means as the opera- 
tor may prefer. Cryptorchid testicles when due to arrest 
in development are not vascular and there is little tendency 
to hemorrhage after excision. Place an antiseptic tampon 
in the wound, pushing it well up against the internal ring 
and retain it in position by means of sutures for a period of 
24 to 48 hours when it is removed and the wound dressed 
antiseptically. 

The operation for cryptorchidy in the smaller animals is 
essentially the same as in the horse except that the incision 
is to be made ordinarily through the flank as in spaying. 
The same attachments are to be our guide and the operation 
is to proceed upon almost parallel lines. 



IV. OPERATIONS ON THE EXTREMITIES. 

33. TENOTOMY OF THE FLEXORS OF THE PHALANGES. 
Plate XXIII. 

Objects. The relief of contraction of the flexor tendons 
of the foot. 

Instruments. Razor, scissors, sharp tenotome, bandage 
material. 

Technic. Tenotomy is generally performed on the 
flexor of the third phalanx, seldom on the superficial flexor 
or flexor of the second phalanx. 

Confine upon the operating table with the affected 
member undermost and the foot fully extended. In default 
of a table confine in lateral recumbency and apply an exten- 
sion splint to the foot as shown in Plate XXIII. 

On the median side at the middle of the metacarpus or 
metatarsus the skin is shaved and disinfected over the 
tendon of the flexor pedis muscle. The location named lies 
between the lower extremity of the great carpal or tarsal 
sheath above and the superior extremity of the tendonous 
sheath of the fetlock below, so that neither of these is 
wounded during the operation, but the tendon is severed at 
a point where it is invested by loose connective tissue which 
retains the divided ends in their normal line of direction, 
somewhat fixed, and favors their ultimate leunion. 

Grasp the metacarpus or metatarsus in this area from 
above and behind in such a manner that the thumb rests 
upon the median or upper surface, and the index and second 
fingers on the lateral or under side of the flexor pedis 
tendon. While the left thumb pushes the skin toward the 
bone, that is, forward, a sharp pointed tenotome held perpen- 
dicularly in the right hand is introduced with the cutting 
edge toward the hoof through the skin, subcutem and anti- 
brachial fascia down to the flexor pedis tendon. Immedi- 










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156 TENOTOMY OF FEXORS OF PHALANGES. 

ately on the anterior border of the tendon insert the teno- 
tome so far that the point of it can be felt on the lateral or 
outer side through the skin with the left hand. 

Care is to be exercised in making this invading incision 
to not include the metacarpal, or metatarsal, arteries, veins 
and nerves. The vascular bundle lying immediately against 
the anterior border of the flexor of the third phalanx, it is 
easy to err by inserting the tenotome in front of the vessels, 
that is between the suspensory ligament and vessels instead 
of between the flexor of the third phalanx and vessels. It 
is safer to make the skin incision far enough posteriorly to 
insure safety to the vessels, cut down upon the tendon, then 
incline the handle of the tenotome backwards, push the 
point of the tenotome obliquely forward and downward 
behind and beneath the vascular bundle and then carrying 
the handle forward bring the instrument to a perpendicular 
position while it is forced down along the anterior surface 
of the tendon until it nears the inferior border when the 
tenotome handle should be carried yet further forward so 
that the point is directed obliquely backward, to facilitate 
its passing between the vessel bundle and the tendon out to 
the skin. The invading incision thus describes the segment 
of a circle, with its concavity backward toward the tendon. 

The cutting edge of the instrument is then turned against 
the tendon, that is, it is directed backward, the foot is ex- 
tended by an assistant with the aid of a rope bound around 
the pastern and looped over the hoof, and the tendon is cut 
through under light pressure, the operator pressing the 
handle of the knife forward and downward, using the meta- 
carpus or suspensory ligament as a fulcrum upon which the 
back of the tenotome rests as a lever. A loud cracking, as 
well as the disappearance of resistance to extension shows 
that the tendon has been severed. 

After the removal of the knife and seeing that there is a 
wide space between the ends of the tendon, the foot is un- 



PERONEAL TENOTOMY. 157 

bound from the splint and a bandage applied to the meta- 
carpus, which rests upon the fetlock joint and remains in 
position for eight days. Healing of the cutaneous wound 
by primary union. 



34. PERONEAL TENOTOMY. 
Plate^ XXIV. 

Object. The relief of Stringhalt. 

Instruments. Razor, scissors, sharp tenotome. 

Technic. On the lateral side of the metatarsus a triangle, 
d, opening toward the tarsus is formed by the tendons of the 
extensor pedis longus muscle, /, and the lateral extensor of 
the foot, e, which unite on the anterior surface of the middle 
of the metatarsus. The synovial sheath of the extensor 
pedis longus muscle extends inferiorly to near the point of 
juncture of the two tendons ; the sheath of the lateral ex- 
tensor ends below 3 to 4 cm. above the point of union. In 
the middle of this space without a sheath, which is 3 to 4 
cm. long, and below the annular ligament of the hock the 
operation is carried out. After the skin has been shaved 
and disinfected, confine in the stocks or operate upon the 
standing horse, with the aid of local anaesthesia, a twitch 
being applied to the nose and the opposite hind foot held up 
with the side-line. The tendon of the lateral extensor is 
easily felt under the skin as a hard cord about 0.7 to i cm. in 
diameter. Stretch the skin and with the back of the hand 
toward the hock grasp and compress the tendon with the 
thumb and-index finger of one hand, insert the tenotome 
with the cutting edge toward the foot perpendicularly upon 
the tendon through the skin, subcutem and aponeurosis 
derived from the crural fascia ; push it from before back- 
ward under the tendon, turn the cutting edge against it, 
and with the hock extended sever the tendon as well as the 




Plate XXIV. 

Peroneal Tenotomy for Stringhalt. 

Right hind foot seen from the external side. 
The skin covering the lateral extensor of the 
foot is laid back in the form of a flap, the crural 
fascia divided. e, Peroneal tendon ; f, crural 
fascia ; /, tendon of the anterior extensor pedis 
muscle ; d, the triangle formed by / and e. 



CUNEAN TENOTOMY 



159 



fascia through to the skin. In accomplishiug the section 
of the tendon the knife is to be used as a lever of the first 
class with the anterior border of the metatarsus acting as a 
fulcrum. If the tendon has been completely severed its 
retracted ends may be felt under the skin i to 2 cm. above 
and below the wound. After the operation an antiseptic 
bandage is applied, resting upon the fetlock. The bandage 
should remain eight days and the cutaneous wound heal by 
first intention. Care should be taken to not wound the 
tendon of the extenson pedis longus muscle. 

Recently it has been proposed to permanently obliterate 
the function of the peroneus muscle by severing its tendon 
within its tarsal sheath above and below the tarsus and 
withdraw the isolated section. The same object ma}^ be 
attained by merely severing the tendon within its sheath 
below the tarsus, if the operation is carried out under aseptic 
precautions because when thus performed the epithelium 
advances over the retracted cut ends and leaves them free 
in the sheath. 



35. CUNEAN TENOTOMY. 
Plate XXV. 

Object. The relief of spavin lameness. 

Instruments. Razor, scissors, straight scalpel, Peters' 
spavin knife. 

Technic. Most horses can be operated on standing, with 
the aid of cocaine, otherwise cast, or secure on the operat- 
ing table, on the affected side and extend the tarsus. Shave 
and disinfect an area 5 to 6 cm. square on the inferior median 
surface of the hock over the course of the cunean tendon of 
the chief flexor of the metatarsus, as indicated in Plate 
XXV. Locate the tendon, CT, by palpation as it passes 
obliquely downward and backward and make a transverse 
incision with a straight scalpel or tenotome, in the form of 




Plate XXV. 

Cunean Tenotomy. 

For the relief of spavin lameness. CT, 
cunean tendon. The dotted line crosses the 
ergot. 



NEUROTOMY. i6i 

a stab wound, merely sufficient lo afford passage for the 
blade of the instrument, about i cm. below its inferior border 
at a point midway between the anterior and posterior borders 
of the hock, or slightly anterior thereto. Push the tenotome 
flatwise between the skin and tendon, as shown in the plate, 
force it upwards to the superior border of the tendon, 
then turn the cutting edge toward it and elevating the 
handle, using the superior border of the skin wound as a 
fulcrum, cut the tendon through from without inwards. 
By firm pressure upon the skin over the tenotome peri- 
osteotomy is simultaneously accomplished. The completion 
of the operation is evidenced by the separation of the cut 
ends of the tendon leaving a well-marked depression at the 
point of division. Disinfect the wound, apply an antiseptic 
tarred bandage resting upon the fetlock and including the 
hock and allow to remain undisturbed for six days. Healing 
by primary union. After the incision through the skin has 
been made, the Peters' knife may be used instead of the 
straight scalpel, and the tendon and periosteum cut through 
at two or three different points, the cuts diverging upwards 
from the cutaneous wound, V-shaped. 



NEUROTOMY. 



General Remarks. Neurotomy is performed for a vari- 
ety of objects, such as the relief of pain in a sensitive nerve 
itself, as in trifacial neurotomy, p. 64, the relief of pain 
or lameness in a part supplied by a sensory nerve, or the 
inhibition of motor power, as in the "cribbing" opera- 
tion by severing the spinal accessory where it passes into- 
the sterno-maxillaris muscle. 

The following neurotomies are designed to relieve pain 
and the consequent lameness dependent upon a pathologic 
condition of some part or tissue on the distal side of the 
II 



l62 NEUROTOMY. 

point of operation and to which the divided sensory nerve 
is destined. 

Neurotomy of a sensory nerve is always a painful opera- 
tion, and its performance without anaesthesia is unjustifiable 
from a humane standpoint, and cannot be so well done either 
from the view of mechanical correctness or the carrying out 
of antiseptic standards. Some neurotomies can be well per- 
formed on the standing animal if it is quiet and the operator 
is experienced, the parts being rendered insensitive by 
means of cocaine or other local anaesthetic ; in the greater 
neurotomies general anaesthesia may be desirable or neces- 
sary from the humane or operative standpoint. 

The confinement of animals for neurotomy on the sensory 
nerves of the extremities for the relief of lameness is always 
to be viewed as a critical procedure for the reason that the 
operation is generally made because of the local manifesta- 
tion of a more or less general disease which may be accom- 
panied by general fragility of the skeleton, and as a result 
most casting accidents occur in cases of confining for 
neurotomy or firing in cases of lameness belonging to the 
great group of dry arthritis or spavin family. Casting must, 
therefore, be done with the greatest possible care, and the 
operating table is to be constantly and greatly preferred. 

Neurotomy is properly a last resort in lameness and should 
not otherwise be performed. It has two great and ever 
present dangers. If the part deprived of sensation is too 
badly diseased to bear the weight and resist the insult result- 
ant upon the part being called to do its normal or even an 
extra amount of work, it must ultimately give way, the 
bones become fractured, the tendons separate from the bone, 
the intra-ungular tissues lose their integrity and the hoofs 
become detached (exungulation) or other degenerative 
changes take place as a result of causing a part to do a 
work for which its condition unfits it. 

The second great danger occurs from wounds or other 
traumatisms to the tissues distal to the operation when the 



NEUROTOMY. 163 

unnerved parts are not rested as they would be in natural 
conditions when injured, and as a result reparative changes 
are prevented and supplanted by retrograde processes with 
ultimate death of the part and of the animal. 

In other words sensory neurotomy robs an organ or tissue 
of the enormously conservative force of pain. Pain causes 
the animal to rest the affected part, protects the painful 
tissues against disintegrating and destructive insults and 
favors restorative processes ; robbed of this protective in- 
fluence of pain by the severance of the sensory nerves, the 
diseased tissues are without their natural protection. 

Nerves are generally accompanied by satellite arteries and 
veins which are always liable to be wounded during the 
neurotomy and are more embarassing because of the hemor- 
rhage clouding the operation field and inviting error than 
dangerous because of the loss of the blood itself. It is 
essential to a good operation that the hemorrhage be kept 
under control throughout so that each tissue will stand out 
in relief and the nerve reveal its identity in addition to its 
location, size and relations, by its intensely white, nacrous, 
striated character. The test of compressing the nerve in 
order to identify it by the resultant pain is unsurgical and 
unnecessarily cruel. 

Sepsis holds an important place in considering the dangers 
of neurotomy because the infection of a sensitive nerve 
causes very great pain and if considerable, tends to cause a 
false neuroma or fibroma in the connective tissue of the 
nerve trunk, calling for a second operation in order to re- 
move the tumor, and resultant lameness. 

Neurotomies should consequently be performed only in 
properly selected cases, the smallest possible trunk that will 
sufficiently relieve the pain should be selected for the opera- 
tion, it should be performed with due regard for suffering 
and for asepsis, should be performed quickly and neatly, the 
incisions being free, laying the nerve trunk bare without 
tearing up the' tissues and clouding them and at every point 
aim at celerity, accuracy and neatness. 



Plate XXVI. 

Digital Neurotomy. 

V, Digital vein ; A, digital artery ; N, principal digital 
nerve ; L, ligament. 



\ 



DIGITAL NEUROTOMY. 167 

36. DIGITAL NEUROTOMY. 
Plate XXVI. 

Objects. The relief of navicular lameness in cases where 
plantar neurotomy is not deemed necessary or advisable. 

Instruments. Razor, scissors, scalpel, probe pointed 
bistoury, tenacula, aneurism needles, bandages. 

Technic. Digital neurotomy may generally be perform- 
ed on the standing animal, the operative area having first 
been anaesthetized by means of cocaine or otherwise, a 
twitch applied to the upper lip and the affected foot held up 
by an assistant. If necessary because of restlessness of the 
animal or inexperience of the operator, confine on the oper- 
ating table or cast the animal and apply the extension splint 
to the foot to be operated on as shown in Plate XXIII, ex- 
cept that the lower binding cords rest on the metacarpus 
instead of the pastern. 

Extending downwards from the fetlock joint toward the 
coronet, between the posterior border of the first phalanx 
and the anterior border of the flexor tendons there is a slight 
furrow, at the posterior part of which, close to the external 
margin of the tendon, lies the median or principal digital 
nerve accompanied in front by the digital artery. A, anterior 
to which Hes the digital vein, V. Immediately behind the 
nerve and generally lying a trifle deeper, is quite commonly 
found a second venous trunk of considerable size. Near the 
middle of the first phalanx the nerve is crossed externally 
in an oblique direction from above to below and from behind 
to before by a white ligamentous band, L, slightly broader 
than the nerve extending from the base of the ergot of the 
fetlock to the retrossal process of the pedal bone. This must 
not be mistaken for the nerve, N, and need not be if it is re- 
membered that the latter is accompanied on the same plane 
and in a like direction by the satellite artery, A, and vein, V, 
enclosed with it in a fibrous sheath. At the uppermost part 
of the first phalanx the nerve lies in front of this ligament, 



-168 DIGITAL NEUROTOMY. 

a short distance inferiorly it passes beneath it, while from 
the middle of the pastern downwards the nerve lies behind 
the ligament. 

The operation is practicable at any point over the line of 
the nerve from the top to the bottom of the shaved area in 
Plate XXVI or from the superior end of the first phalanx 
down to a level with the superior border of the lateral carti- 
lage, but preferably at about the point shown in Plate XXVI , 
near the superior end of the first phalanx. At the desired 
point and over the groove between the flexor pedis tendon 
and the phalanges shave and disinfect an area 4 to 5 cm. 
square. In the center of this area at the anterior border of 
the flexor tendon, with the scalpel held perpendicular to 
the skin, make an incision from above downwards a distance 
of from 2 to 3 cm. cutting cleanly through the skin and 
subcutaneous fascia down upon the nerve. The incision is 
favored by tensing the skin between the thumb and index 
finger of the left hand, but care should be taken not to dis- 
place it backwards or forwards. Dilate the wound by 
pressure upon the skin with the thumb and index finger or 
otherwise and carefully incise longitudinally the fibrous 
sheath enveloping the nerve and artery. Pass an aneurism 
needle beneath the nerve, and forcing it upward and down- 
ward, separate thereby the nerve from the surrounding 
tissues. Insert a probe pointed bistoury, or scissors beneath 
the nerve, and divide it at the upper angle of the wound 
and excise a section 3 cm. long. Disinfect and bandage 
with or without suturing the wounds. Leave the bandage 
in place 6 to 8 days. 



PLANTAR NEUROTOMY. l6g 

37. PLANTAR NEUROTOMY. 
Plate XXVII. 

Object. The relief of navicular, or ringbone lameness 
or other painful, non-suppurating disease of any parts below 
the fetlock joint. 

Instruments. Razor, scissors, convex scalpel, compres- 
sion arter}^ forceps, tenacula, aneurism needles, suture ma- 
terial, elastic ligature. 

Technic. It is well to shave the site of operation and 
thoroughl}^ disinfect the region of the metacarpus and fet- 
lock with soap, brush, and sublimate or creolin solution and 
50% alcohol, and apply a bandage saturated with sublimate or 
creolin solution to the fetlock joint 24 hrs. before the 
operation in order to secure thorough disinfection. 

Confine the animal and fix the limb as in the preceding 
operation. After the removal of the disinfecting bandage, 
and producing local anaesthesia pass the fingers from 
before to behind with light pressure over the region just 
above the fetlock joint, where there is felt immediateh^ in 
front of the flexor pedis tendon a channel-like depression 
extending from above the fetlock downward over it. Just 
at the anterior margin of the flexor pedis tendon and at 
the posterior part of the groove lies the threadlike cord 
of the nerve, 71, 3 mm. thick, which glides away from 
underneath the fingers with a distinct recoil. The site of 
operation lies immediately above the fetlock in the posterior 
third of the metacarpus or one may operate at any point 
higher up as far as beyond the middle of the metacarpus or 
metatarsus s"o long as care is taken to include the anasto- 
mosing branch given off by the median plantar nerve at 
about the middle of the metacarpus and bending obliquely 
around behind the tendons to join the lateral nerve some- 
what lower down. At this point stretch the skin between 
the thumb and index finger of one hand and make an in- 



Plate XXVII. 

Plantar Neurotomy. 

a, lateral digital artery ; v, lateral digital vein ; 
n, common lateral digital nerve ; d, anterior 
branch ; o, posterior branch ; s, superficial flexor 
tendon ; p, perforans tendon ; i, suspensory 
ligament of fetlock ; in, metacarpus. 



PLANTAR NEUROTOMY. jy^ 

cision 3 to 5 cm. long, the lower angle of which is usually 
just above the fetlock joint, cutting directly through the 
skin, subcutera and connective tissue sheath down onto the 
nerve, laying it bare. The borders of the cutaneous wound 
are held apart with tenacula and by palpation with the 
fingers or by vision it is determined if the nerve lies in the 
middle of the wound. If necessary continue the dissection 
with the scalpel until the nerve is clearly revealed ; it is 
distinguished by its faintly yellowish color, its fine longi- 
tudinal striae and its location behind the metacarpal artery. 
Immediately above the fetlock joint the median metacar- 
pal or metatarsal nerve divides into an anterior smaller, d, 
and posterior larger branch, o. This division should be 
laid bare in order that the operator may not erroneously 
cut one branch only. Immediately above this point of 
division the aneurism needle is passed under the nerve, 
pushed well through and forced up and down,, separating 
the nerve from the adjacent tissues, the scissors or a small 
probe-pointed bistoury is passed beneath and it is cut 
through quickly at the superior angle of the wound. The 
distal end of the nerve is then dissected free downward 
and excised at the lower angle of the wound so that a section 
3 to 5 cm. long is removed. The cutaneous wound is united 
by a continuous suture and a temporary bandage applied. 
If the horse has been secured by casting, the extension 
splint, if it has been used, is then removed, the foot replaced 
in the hobble and the horse turned to the other side. The 
operation on the opposite metacarpal nerve is carried out 
in the same way after which a sterile bandage is applied and 
allowed to remain eight days. Healing by primary union. 



1 7 4 NE URO TO MY OF THE MEDIAN NER VE. 

38. NEUROTOMY OF THE MEDIAN NERVE. 
Plate XXVllL 

Objects. The relief of lameness due to disease so located 
in the anterior limb that it cannot be so well overcome by 
plantar neurotomy. 

Instruments. Razor, scissors, convex scalpel, artery 
and compression forceps, tenacula, aneurism needles, suture 
material. 

Technic. The operation is performed on the median 
surface of the anterior limb immediately below the humero- 
radial articulation on the recumbent horse after the affected 
foot has been fully extended on the operating table or in de- 
fault of this removed from the hobbles and bound upon the 
extension splint as shown in Plate XXIII. Anaesthetize. 

The foot is drawn out firmly from the shoulder, inclined 
somewhat forward. The operator places himself between 
the neck and the forearm of the patient and, after the median 
region of the elbow joint has been washed with soap and 
water, searches for the median nerve where it glides over 
the posterior part of the joint to disappear behind the radius. 
Shave the skin at and below this point, disinfect it with 
sublimate or creolin solution and 50% alcohol. The nerve, 
n, lies as a rule somewhat in front of the middle of the 
median side of the forearm against the postero-internal 
margin of the radius and can be felt, about 5 to 6 mm. in 
diameter, lying somewhat deeply. The position of the 
nerve varies with the different attitudes of the forearm. In 
fat and fleshy horses the identification of the nerve is more 
difficult. It may be felt upon the standing animal. 

With the nerve lying between the thumb and index finger 
of the left hand, at the point where it begins to disappear 
behind the radius after having passed over the humero- radial 
articulation, stretch the superposed skin and immediatel}^ 
upon and parallel to it make an incision 5 cm. long, first 
through the skin, then through the aponeurotic expansion 



NEUROTOMY OF THE MEDIAN NERVE. 175 

of the sterno-aponeuroticus muscle. Check any hemorrhage 
from the skin, subcutis, or muscle. The tenacula are in- 
serted cautiously in the lips of the wound, and these being 
drawn apart the white anti-brachial fascia is brought into 
view and a search is made with the index finger to determine 
the exact location of the nerve, the fascia is divided with 
the scalpel and an oval piece excised with the scissors im- 
mediately over the nerve. If much fatty tissue is found be- 
neath the fascia it may be dissected away carefully with the 
scalpel or cut away with the scissors. There now comes in- 
to view a delicate reddish colored fascia-like membrane, the 
nerve sheath, behind which a dark cord, the brachial vein, 
V, is visible, the latter being intimately connected with the 
nerve sheath. The vein lies mostly behind and beneath the 
nerve and may project out from beneath the border of the 
same. The operator fteeds be careful not to prick this vein with 
the tejiacula, as the hemorrhage therefrom is exceedingly annoy - 
hig during the operation. Avoid the use of tenacula after pene- 
trating the fascia and retract the woimd lips cautiously ivith 
aneurism needles instead. Still further forward and deeper 
may be felt the pulsating brachial artery. Incise the nerve 
sheath carefully and divide it upward and downward with 
the scalpel or scissors, whereupon the yellowish and dis- 
tinctly fibrous nerve comes into plain view. Pass an 
aneurism needle beneath the nerve pushing it so far through 
that the distal end is readily grasped and drawing it up and 
down with the two hands, separate the nerve from the 
adjacent tissues throughout the length of the wound. 
Be careful to 7iot cut the nerve too high ajid erroneously 
include the motor nerve of the flexor of the metacarpus a7id 
the flexors of the foot, which is generally give^i off posteri- 
orly just below the hiunero radial articulation. Lift the nerve 
up and cut it through at the superior angle of the wound 
by a sudden clip with the scissors or with the probe pointed 
bistoury. Lay the peripheral end of the nerve bare to the 
lower angle of the wound, and excise at least 3 cm. of it. 



Plate XXVIII. 

Median Neurectomy. 

Median surface of the right humero radial 
articulation. a, brachial artery ; ;/, median 
nerve ; z\ brachial vein ; f, antibrachial fascia ; 
p, sterno-aponeuroticus muscle. 




12 



NEUROTOMY OF THE ULNAR NERVE. lyg 

Tamponade the wound with dry iodoform gauze and ap- 
proximate the skin with a continuous suture. The tampon 
and sutures remain i to 2 days. 

Since sensation of the lower part of the limb is partly 
maintained by the deep branch of the ulnar nerve which at 
the lower part of the carpus, covered by the tendon of the 
oblique flexor becomes the lateral plantar nerve, neurotomy 
of the median nerve does not always completely effect the 
desired end. In order to produce complete anaesthesia of 
the foot, therefore, it is necessary to perform ulnar 
neurotomy. 



39. NEUROTOMY OF THE ULNAR NERVE. 
Plates XXIX-XXX. 

Object. An adjunct operation of the preceding b}" 
which the enervation of the carpus and foot is completed. 

Instruments. Same as in the preceding. 

Technic. Above and behind the carpus there may be 
felt a groove between its external and middle flexors, KF 
and OF, Plate XXX. At this point 10 cm. above the 
pisiform bone the skin is shaved and disinfected and an in- 
cision 6 cm. long made through the skin and antibrachial 
fascia. This incision extends just outside the median line 
of the posterior surface of the radius in such a way that the 
superior angle of the wound is about i cm. farther out- 
ward than the lower. Beneath the fascia between the 
aforesaid muscles is seen the ulnar nerve, Plate XXIX, n 
Plate XXX, NU, on the median or inner side of it the 
collateral ulnar vein, Plate XXIX v, and between the two 
and somewhat deeper the collateral ulnar artery, a. The 
nerve, about 3 mm. in diameter is picked up with the 
aneurism needle, severed at the upper and lower angles of 
the wound, the lips of the wound united by a continuous 
suture and a bandage applied. Healing by first intention. 



Plate XXIX. 



Ulnar Neurotomy. 



Right forearm seen from behind, e, external 
flexor of the carpus ; f, oblique (middle) flexor 
of the carpus ; a, collateral ulnar artery ; b, 
antibrachial fascia ; «, ulnar nerve. 



Plate XXX. 

Ulnar Neurotomy. 

Cross section through the forearm, about 
lo cm. above the pisiform bone, viewed from 
below. EF, external flexor of the carpus ; 
OF, oblique flexor of the carpus ; NU, ulnar 
nerve ; NM, median nerve. Lying on its median 
side is the ulnar artery, the satellite vein of 
which is not shown. 



\ 



SCI A TIC NEURO TOMV. 1 85 

40. SCIATIC NEUROTOMY. 
Plates XXXl-XXXll. 

Objects. The destruction of sensation in the tarsus and 
parts beyond for the relief of otherwise incurable spavin 
lameness, diseases of the tendons, etc. 

Instruments. Same as in the preceding. 

Technic. Expert surgeons may operate on the standing 
animal under local anaesthesia. Place the animal on the 
operating table on the diseased side, extend the affected 
limb and draw the upper leg forward or backward and 
secure it out of the way. Produce complete general or local 
anaesthesia. The posterior tibial or sciatic nerve, ;z, Plate 
XXXI and NS, Plate XXXII, is then sought by grasping 
the leg with the left hand from behind in such a manner 
that the thumb rests above and the fingertips below it. 
Reaching forward with the fingers to the deep flexor of the 
foot grasp the leg with moderate firmness and draw the 
band slowly backward. Immediately behind the perforans 
muscle and between this and the tendo- Achilles the nerve, 
nearly i cm. in diameter, glides away forward from be- 
tween the fingers with a distinct recoil. If the nerve can 
not be recognized in this manner the hock should be more 
strongly extended, by which means the nerve may be caused 
to recede from the perforans muscle, so that it can more 
readily be felt near the middle of the groove extending be- 
tween it and the tendo-Achilles. 

At this point on the median side of the leg the skin is 
shaved, disinfected and an incision made through it 5 cm. 
long, parallel to the tendo-Achilles. The white rigidly- 
stretched crural fascia is now divided in the same direction 
after which it should be determined by palpation that the 
nerve lies in the middle of the wound. Excise with the 
scissors an elliptic or oval piece of the fascia or hold it 
apart along with the lips of the cutaneous wound by means 



Plate XXXI. 

Sciatic Neurotomy. 

Right hind leg viewed from the median side, 
y, crural fascia; n, sciatic (tibial) nerve; v, 
plantar vein. 



Plate XXXII. 

Tibio- Peroneal Neurotomy. 

Cross section through the tibia at about lo cm. above the tibio- 
astragaloid articulation. SA, recurrent tibial artery; NS, sciatic 
nerve ; NMC, musculo-cutaneous branch of anterior tibial nerve ; NP, 
deep or sensory branch of anterior tibial or peroneal nerve ; EP, ex- 
tensor pedis muscle ; MP, peroneus muscle ; FM, flexor metatarsi 
muscle. 



ANTERIOR TIBIAL NEUROTOMY. 191 

of the tenacula. In poor horses the contour of the nerve, 
covered only by loose connective tissue, stands out promi- 
nently, in fat horses it is surrounded by a large amount of 
adipose tissue. Cut through this fat and connective tissue 
and expose the tibial nerve, /z, Plate XXXI and NS, Plate 
XXXII, to view ; immediately before it lies the plantar 
vein and on the lateral side is situated the recurrent tibial 
-artery, SA, Plate XXXII. The cross section in Plate 
XXXII is located somewhat below the point for operation 
and the vein has crossed obliquely over the nerve so that 
it appears behind instead of m front of it, as is the case 
generally at the point where the operation is performed. 
Separate the vessels completely from the nerve with the 
handle of the scalpel, pass an aneurism needle from before 
backward beneath it through to the handle and grasping 
both ends force the instrument upwards and downwards in 
•order to separate the nerve trunk from the adjacent tissues. 
Cut the nerve off at the upper and lower angles of the 
wound removing a section at least 5 cm. long. Suture the 
cutaneous wound and apply a bandage allowing it to remain 
•eight days. Healing should occur by first intention. 



41. ANTERIOR TIBIAL NEUROTOMY. 

Neurotomy of the Deep Branch of the Peroneal Nerve. 

Plates XXXII-XXXIII. 

Object. An adjunct operation to the preceding since this 
nerve supplies sensation to the tarsus in common with the 
sciatic. The two constitute what is known as Bossi's double 
neurotomy for spavin. 

Instruments. Same as in the preceding. 

Technic. Confine as in the preceding but with the 
-affected leg uppermost. Locate the furrow dividing the 



Plate XXXIII. 

Anterior Tibial Neurotomy. 

EP, extensor pedis muscle ; P, peroneus- 
muscle ; NP, deep branch of the peroneal or 
anterior tibial nerve ; FM, flexor metatarsi 
muscle. 




13 



ANTERIOR TIBIAL NEUROTOMY. 195 

extensor pedis longus, EP, Plates XXXII-XXXIII, and 
the peroneus muscles, P, Plate XXXIII, MP, Plate XXXII, 
and shave and disinfect an area 6 cm. long by 3 cm. wide 
directly over this depression and extending upward from a 
point 6 to 7 cm. above the tibio-astragaloid articulation. 

At a point 8 to 10 cm. above the flexure of the hock make 
an incision through the skin and subcutis 5 or 6 cm. long 
over the line of division between the two extensors of the 
foot. Superficially the operator passes near by the musculo- 
cutaneous division of the anterior tibial nerve, NMC, Plate 

XXXII, which must not be mistaken for the deep branch. 
The peroneus muscle, MP, Plate XXXII, and P, Plate 

XXXIII, is separated from the extensor pedis longus, EP, 
Plates XXXII and XXXIII, by a strong aponeurotic sheath 
continuous with the tibial aponeurosis. Penetrate the tibial 
aponeurosis a7iterior to the aponeurotic partition directly 
against the extensor pedis, EP, and passing along the 
posterior border of this muscle to a depth of 2 to 4 cm., 
there appears the thin margin of the flexor metatarsi 
magnus, FM, Plates XXXII and XXXIII, which lies im- 
mediately against the extensor pedis without a visible con- 
nective tissue partition but revealing itself by a markedly 
lighter shade of color and its ready separation from the ex- 
tensor with the scalpel. The deep branch of the peroneal 
nerve, NP, Plates XXXII and XXXIII, lies loosely im- 
bedded on the anterior side of the margin of the flexor meta- 
tarsi facing the extensor pedis, at times visible at the margin, 
at others placed more deeply reaching in some cases a distance 
from the margin of 4 or 5 mm. Within this range is seen 
the slender nerve trunk almost devoid of surrounding con- 
nective tissue and measuring about 2 mm. in diameter. 
Pass the aneurism needle beneath it and remove a piece 3 
to 4 cm. long. Close the cutaneous wound with interrupted 
sutures and dress antisptically without a bandage. 



196 RESECTION OF THE LATERAL CARTILAGE. 

42. RESECTION OF THE LATERAL CARTILAGE. 

The Bayer Quittor Operation. 

Plate XXXIV. 

Object. The cure of quittor or necrosis of the lateral 
cartilage. 

Instruments. Elastic ligature, drawing knife, scissors, 
razor, hoof rasp, hoof plane, craniotomy or other heavy for- 
ceps for the removal of the horn, artery forceps, elevator or 
long bone chisel, right and left sage knives, curette, needle 
holder, thread, needles, iodoform ether, iodoform gauze, 
tampons, absorbent cotton, bandages. 

Technic. For a few hours before the operation place 
the affected foot in a bath of creolin or other antiseptic 
solution after having first rasped the diseased quarter lightly 
and make a semicircular groove in the horn of the lateral 
wall and quarter down to the horny lamina, as shown at s 
in Fig. I, Plate XXXIV. It is essential to not materially 
thin the horn on the quarter with the rasp since by weaken- 
ing it, it yields and breaks and cannot be properly detached 
from the senitive laminae. 

The operation is peformed upon the recumbent, anaes- 
thetized animal, in such a position that the diseased cartilage 
of the affected foot lies upward. The operating table consti- 
tutes incomparably the best means of confinement in every 
respect. After the application of the elastic ligature in the 
metacarpal or metatarsal region the groove in the horn is 
deepened with the drawing knife down to the sensitive 
laminae without injuring them. The groove must be so 
located that it extends beyond the anterior and posterior 
borders of the lateral cartilage, and downwards to within i 
or 2 cm. of the margin of the os pedis and approximately 
perpendicular to the surface of the horn wall so that it will 
form a secure support for the dressing to be later applied. 
The hair on the coronary band is clipped or shaved and the 



RESECTION OF THE LATERAL CARTILAGE. 197 

entire foot up to the fetlock joint thoroughly cleansed with 
brush, soap, creolin or sublimate solution and 50 per cent, 
alcohol. The fetlock and pastern are carefully wrapped in 
a towel saturated with sublimate solution or other disin- 
fectant. The hoof should be similarly wrapped except the 
operative area and every precaution taken against the 
transfer of infecting material from neighboring parts into 
the wound. The elevator or long bone chisel is then inserted 
beneath the lowest part of the semi-circular piece of horn 
which has been isolated, the horn is elevated from the 
sensitive structures somewhat, grasped with the heavy for- 
ceps and carefully loosened from the sensitive parts by 
drawing upward parallel to the laminae until the coronary 
band is reached and the traction is then directed backwards 
toward the heel, separating the wall from the coronary 
papillae and keraphyllous tissue. Care is to be taken here 
to avoid lacerating the underlying tissues, especially when 
the traction is first directed backwards. If the soft tissues 
threaten to tear this should be arrested by the timely use of 
the scalpel or sage knife as conditions may suggest. 

After the coronary band has been smoothed with the 
scissors, make two perpendicular incisions through the skin 
and coronar}^ band, one behind the anterior and the other in 
front of the posterior border of the groove in the horn and 
connect the two by means of a semi-circular incision in the 
sensitive laminae. This U-shaped incision should be so 
made that between it and the horny wall there is left an 
area of sensitive laminae i to 2 cm. wide, in order that there 
may be sufiicient room in the soft tissues for the application 
of the sutures, as shown in Fig. 2. The lines of incision 
through the coronary band should be so located as to in- 
clude between them the entire lateral cartilage. 

The isolated flap is now dissected closel}- against the os 
pedis and its ala and from the lateral surface of the carti- 
lage, the operator lifting the flap with forceps or tenaculum. 



Plate 




Fig. 1, 

Resection of the Lateral Cartilages of the os Pedis. 

Horny wall removed, sensitive laminae and cutaneous flap held 
upwards. Posterior half of the cartilage excised. /, sensitive lam- 
inae ; w, coronary band ; k, anterior half of cartilage ; h, cavity 
caused by the removal of the posterior half of the cartilage ; n, necrotic 
cartilage ; p, parachondral surface of the skin and sensitive laminae ; 
s, perpendicular, crescent-shaped incision in the horny wall ; g, fistula. 



XXXIV. 




Fig. 2. 

Resection of the Lateral Cartilages of the os Pedis, 

Completed operation showing the sutures in place and the^parts 
ready for the application of dressings. 



200 RESECTION OF THE LATERAL CARTILAGE. 

Above the cartilage toward the fetlock the operator must 
keep the fingers of one hand against the external skin in 
order to avoid cutting through it or thinning it too much 
at this point. The flap is held turned upwards by an assist- 
ant or a strong suture is passed through it and turning it 
upwards the suture ends are carried around the pastern and 
tied. 

As a rule there is now seen a prominent, greenish colored 
necrotic piece of cartilage surrounded by brownish red 
masses of granulations. By means of an incision through 
the cartilage parallel to the long axis of the foot, divide it 
into anterior and posterior halves and extirpate the latter 
first by dissecting it out on the inner side from the para- 
chondral tissue with the sage knife. Begin the excision 
of the cartilage by engaging the supero-anterior angle of 
the posterior half with the tenaculum and exerting moderate 
traction dissect it away from the underlying tissues first 
along the line of the dividing incision down to the base and 
then cut backward toward the heel cutting the cartilage 
away from its continuous bone. The point of the knife must 
be constantly directed against the cartilage. 

Since the inner surface of the anterior half of the cartilage 
lies immediately against the capsular ligament of the corono- 
pedal articulation the latter should be sharply extended by 
an assistant seizing the toe and forcing it forward. By 
this means the capsular ligament is drawn away from the 
cartilage during its extirpation. 

The anterior half of the cartilage, k, is then removed in 
the same way, except with the greatest possible care to 
avoid puncturing the corono-pedal articulation-. The chief 
precaution is to dissect only with the point of the sage knife, 
using at all times that knife, right or left, which will result 
in the concave surface being presented toward the cartilage ; 
then by carefully keeping the line of excision immediately 
.agai7ist the cartilage, material danger of penetrating the 






RESECTION OF THE LATERAL CARTILAGE. 201 

joint is avoided. Remnants of cartilage at its juncture 
Tvith the retrossal process of the os pedis, and granulations 
are to be removed with the curette. Cut away with the 
scissors and knife any remnants of cartilage adherent to 
the flap, p, thin if necessary the entire flap and excise the 
fistulous openings, g. After thorough disinfection of the 
entire field of operation sprinkle it over thickly with 
powdered iodoform and return the flap to its former position 
and retain it there by a sufiicient number of interrupted 
sutures as shown in Fig. 2. The first sutures to be applied 
should be at the border line between the skin and coronary 
band so as to insure accurate apposition at this point. 
Sprinkle the wound surface with iodoform and cover the 
parts over with iodoform gauze and tampons which rest 
firmly upon the perpendicular wall of horn. Finally invest 
the hoof and pastern up to the fetlock joint with an abund- 
ance of oakum saturated with i-iooo sublimate solution 
and lay a heavy tar bandage over it, the turns of which 
must completely invest it at every point and render the 
dressing impermeable to moisture. Remove the elastic liga- 
ture. If the animal is free from fever, feels and eats well, 
the bandege is left in position from 12 to 14 days. Healing 
by first intention. 

The two chief dangers in the operation are the opening 
of the corona-pedal articulation and the persistence of a 
scar in the coronary band resulting in a quarter crack. 

If the operation has been kept thoroughly antiseptic, the 
opening of the articulation is not necessarily serious. 

The question of preventing a weakening scar at the 
coronary incision is one of strict antisepsis and accurate 
suturing. The operation frequently fails under indifferent 
technic. It is an operation for the careful surgeon only. 



202 RESECTION OF THE FLEXOR PEDIS TENDON. 

43. RESECTION OF THE FLEXOR PEDIS TENDON. 
Fig. 15. 

Object. The removal of necrotic tissues and disinfection 
in cases of infected wounds, chiefly of nail wounds of the 
navicular bursa. 

Instruments. Elastic ligature, drawing knife, sage 
knives, scissors, tenaculum forceps, curette, scalpels,, 
tenaculse, bandage material. 

Technic. Before the operation thin the horn of the sole,, 
frog and bars until the soft parts can be seen through them 
and apply an antiseptic bandage saturated in creolin solution 
for 24 hours if time will warrant. Secure the patient on the 
operating table or by casting in lateral recumbency with the 
affected foot extended. Anaesthetize. Cleanse and disinfect 
the entire foot with :5oap, brush, creolin or sublimate solution 
and 50% alcohol and apply the elastic tourniquet in the 
metacarpal or metatarsal region. Apply towels saturated 
with antiseptics as in preceding operation. Make a trans- 
verse incision through the base of the frog 2 to 3 cm. from 
the balls through the horny and sensitive portions and the 
fatty cushion down to the flexor pedis tendon. Follow this- 
by two converging incisions extending forward and inward 
in an oblique direction corresponding to the semi-lunar crest 
of the OS pedis, the line of incision being in the bars about 
y2 cm. outward from the lateral groove of the frog and 
uniting at its apex. This triangular piece of frog which 
has been isolated by the incision is now grasped with the 
tenaculum and dissected away. The remnants of the fatty 
frog should be removed with the sage knife or scalpel by 
means of a horizontal incision, and there is then revealed 
the flexor pedis tendon which may be greenish or yellowish 
colored and necrotic, or may be covered with reddish colored 
granulations. 



RESECTION OF THE FLEXOR PEDIS TENDON. 



203 



Should there be present also suppurative pododermatitis 
the bars on the affected side must be excised along with 
the other portions. 

The position and extent of the navicular bone can be 
determined by palpating the flexor tendon. A transverse 
incision is then made over the middle of the navicular bone 




Fig. 15. 

Resection of the Flexor Pedis Tendon. 

Solar surface of the foot, c, Semi-lunar crest of os pedis ; 
u, OS pedis ; r, navicular-pedal ligament ; s, navicular bone ; 
b, flexor pedis tendon ; e, sensitive laminae of the bars ; st, 
fatty frog ; f, sensitive frog ; /z, horny frog. 

through the flexor pedis tendon into the navicular bursa, 
the distal end of the tendon grasped with the tenaculum 
forceps and lifted up from the navicular bone with the aid of 
two lateral curved incisions. Between the inferior or anterior 
border of the navicular bone and the semi-lunar crest of the 
OS pedis stretches the capsular ligament of the inferior 
articulation reinforced by dense fibrous bands. The flexor 



204 AMPUTATION OF THE CLAWS OF RUMINANTS. 

pedis tendon is united to this by a few bundles of fibres. 
Dissect the tendon carefully away from the capsular liga- 
ment, avoiding opening the articulation, and then cut it 
away from the semi-lunar crest of the os pedis. If necrotic 
or discolored pieces of the fatty cushion or the tendon still 
remain, remove these with scissors, scalpel or curette. 
Curette the roughened cartilage of the navicular bone and 
remove any necrotic or inflamed, softened portions of the 
bone. In extensive necrosis of the suspensory ligaments 
of the heel and of the ligaments extending from the 
fetlock joint to the lateral cartilages, the necrotic portions 
as well as the neighboring fatty cushion with its numer- 
ous elastic fibres, must be resected. In case of purulent 
areas extending along the tendon and opening above in 
the heel, draw through the tract a large strip of gauze 
thoroughly saturated with tincture of iodine and allow it to 
remain. If the suppurating area extends well up into the 
heel without an opening, incise from above and handle as 
preceding. Disinfect the operation wound, irrigate with 
iodoform ether and tamponade it with dry iodoform gauze. 
Over this apply a firm pad of oakum saturated with i-iooo 
sublimate, enclose the entire hoof up to the fetlock in oakum 
and apply over this a bandage. Over this apply a tar 
bandage and remove the elastic ligature. In the absence of 
fever the bandage remains in position for 8 to 12 days. 



44. AMPUTATION OF THE CLAWS OF RUMINANTS. 
Plate XXXV. 

Uses. The cure of "foul in the foot" or panaritium 
when complicated with suppurative arthritis or osteitis. 

Instruments. Half round rasp, sage knives, scissors, 
convex scalpel, artery forceps, drawing knife, elastic liga- 
ture, dressing materials. 



\ 



AMPUTATION OF THE CLAWS OF RUMINANTS. 



205 



Technic. Cast the animal and secure the foot to be 
operated upon in an extended position, apply the elastic 
ligature and after disinfecting the claws rasp away the horn 
on the lateral side of the diseased claw, especially at the pos- 
terior part of it, until the horny wall becomes so thin that 
it can readily be pressed in with the fingers. Anaesthetize. 
The corono-pedal articulation can be felt, about 3 cm. below 
the coronary band, by grasping the claw with the left hand 
in such a manner that the thumb rests upon the thinly 
rasped horn while with the other hand the claw is moved 
from side to side. At the lowest point of the articulation 
push the sage knife into the joint, the concavity of the 
knife being directed toward the leg, and make a curved in- 
cision at first forward and upward to the neighborhood of 
the coronary band, then with strong flexion of the foot a 
second curved incision backward and upward which, how- 
ever, extends only to the navicular bone. By this incision 
the operator divides the horn, the sensitive lamina, the ex- 
ternal corono-pedal ligament and the capsular ligament of 
the corono-pedal articulation. Pass the knife between the 
navicular and pedal bones and extend the incision down- 
wards perpendicular to the solar surface through it, sepa- 
rating the navicular bone from the os pedis. In this manner 
the navicular bone is preserved as well as the ball of the 
heel, the latter of which is of special significance in healing. 
The inner wall of the claw with the powerfully developed 
corono-pedal ligament is divided from before backward. 
After the vessels which can be seen are ligated, the articular 
surfaces of the navicular and coronary bones curetted and 
the necrotic remnants of tendon removed an antiseptic 
bandage is applied and a tar bandage placed over it for pro- 
tection. The bandage remains for 12 or 14 days. 

If the structures above this point of amputation are 
irremediably involved the digit should be amputated higher 
up, at the articulation of the first and second phalanges or 
through the first phalanx. In these higher amputations a 
flap operation is generally practicable. 



Plate XXXV. 

Amputation of the Claws of Ruminants. 

Fig. I. d, horny wall, rasped thin ; g, artic- 
ular condyle of 2nd phalanx ; a, b, c, course of 
incision. 

Fig. 2. Median claw preserved. Viewed 
from the solar surface outward. a, external 
corono- pedal ligament ; ?', internal do ; /^, ten- 
don of the flexor pedis muscle ; g, distal artic- 
ular surface of the 2nd digit ; g^ articular sur- 
face of 3rd digit ; g^^, navicular bone ; /, lateral 
claw : in, median claw ; b, bulb of the heel. 




Fig. 2, 



THE BAYER SUTURE. 209 

45. THE BAYER SUTURE. 
Figs. 16 and 17. 

Uses. The closure of large or penetrant wounds with 
convenient and secure means for applying and retaining 
antiseptic dressings. 

Instruments. Large curved suture needle armed with 
strong silk thread, about 20 cm. long, which is doubled and 




Fig. 16. 

Retention, and Continuous Approximation Sutures. 

d, d^, d'\ drainage tubes ; <?, retention suture (closed end); e\ open 
end ; h, fixation suture for the drainage tube ; /, continuous approxi- 
mation siiture. 

passed through the needle eye in such a manner that the loop 
extends considerably beyond the cut ends ; small needles 
and thread ; needle forceps ; rubber tubing preferably two 
large pieces and one small with lateral openings ; thin wooden 



2IO 



THE BA YER SUTURE. 



splints 15 cm. long, 2 to 4 cm. wide, with rounded ends ; 
iodoform gauze ; iodoform ether 1:10. 

Technic. After the skin has been shaved over an area 
having a radius of 5 to 6 cm. from the wound, the suture 
needle is inserted 2 to 3 cm. from the lips through the skin 
and subjacent tissues, a piece of the rubber tubing, d' , passed 




Fig. 17. 

Splint Bandage. 

d, d\ d'\ drainage tubes ; <?, retention suture (closed ends); e^ , do, 
open end ; 7, iodoform gauze ; s, splints. 

through the closed end of the suture and the thread drawn 
tight. If before threading the needle a clove hitch is made 
at the middle of the thread, or if threaded as above directed 
and the thread is thrown about the tube in a double noose, 
the two threads will be kept in contact as they leave the tube 
to enter the soft tissues and thus prevent to some degree, 
the pressure necrosis otherwise taking place, due to the tense 



THE BA YER SUTURE. 2 1 1 

threads of the suture separating from each other. The 
needle is then passed through the opposite lip of the wound 
from within to without at the same distance from the lips, 
the needle removed, the free ends drawn taut and a single 
knot tied against the skin to prevent the separation of the 
two threads for the reasons just stated above. The second 
large tube, d" , is laid between the open ends of the double 
silk thread and these are tied upon it with a triple knot, 
after the}^ have been drawn sufficiently tight that the 
approximated wound lips form a crest. If the lips of the 
wound can be grasped with the hand and held together in 
such a manner as to form a ridge 3 or 4 cm. long, the 
suture needle may be passed through both simultaneously. 
The first suture should be located about 3 cm. beneath the 
upper angle of the wound, the other retention sutures follow 
at distances of about 5 cm. from each other and applied in 
the same way. 

The lips of the wound are then united by continuous 
approximation sutures like an overcasted seam. This 
suture ends at least 2 cm. above the lower angle of the 
wound. The third tube, for drainage, is introduced be- 
neath the latter sutures and fixed by a special suture. 

The entire cutaneous surface lying between the drainage 
tubes is covered with iodoform gauze, and between each two 
retention sutures there is laid over this gauze the wooden 
splints previously cut to the proper size, the ends of which 
are pushed under the tubing. The upper- and lowermost 
splints should be secured to the drainage tubing by means 
of sutures passed through them. The entire bandage is 
finally saturated with iodoform ether. The bandage and 
retention sutures remain eight days, the approximation 
sutures fourteen. 



II. EMBRYOTOMY OPERATIONS. 

Fig. 18. 

General Considerations. The following exercises in 
embryotomy operations are designed to give to the student 
a general view of the subject by a simple plan as carried 
out through the aid of a skeleton provided wath an artificial 
uterus into which are placed freshly killed, newly born 
calves in such a position as may be desired and the opera- 
tions carried out by the student as described. At the same 
time it is hoped to offer through these descriptions to the 
veterinary obstetrist a simple and effective plan for perform- 
ing embryotomy which has been fully tested by the author 
in an extensive obstetrical practice. In describing these 
operations we purposely limit the instruments to be used to 
the fewest number and simplest kinds, yet using all that are 
essential in the performance of any of the following obstet- 
rical operations. We designate the same instruments for 
each operation. They are, see Fig. i8 : a hooked ring knife; 
a Colin's scalpel ; an embryotomy chisel ; long blunt hook ; 
short blunt hook ; repeller ; probe pointed sector ; injection 
pump ; mallet ; several cotton ropes i cm. in diameter with 
a small spliced loop at one end. 



46. CEPHALOTOMY. 



Object. The diminution of the size of the head on ac- 
count of its oversize or of the smallness of the maternal 
pelvis, so that it may pass through the pelvic canal. 

Technic. In these cases the head is usually engaged in 
the canal sufficiently tight that no further fixation is neces- 
sary. Should further fixation be desired, fix the long blunt 
hook deeply in one orbit. After thoroughly cleansing and 
disinfecting the parts inject a copious amount of tepid lysol 



CEPHALOTOMY. 



213 



or bacterol solution into the vagina, then carry the chisel 
carefully guarded by one hand into the passage and place 
it accurately upon that part of the head of the fetus where 
it is desired to begin the operation ; generally on the median 
line of the nose with the blade of the chisel standing 
parallel to the septum nasi of the fetus. Holding the blade 




Fig. 18. 

Aseptible Embryotomy Outfit. 

A, embryotomy chisel ; B, repeller ; C, sector ; D, long blunt 
hook ; E, short blunt hook ; F, ring knife ; G, hook knife ; H, 
Colin 's scalpel. The lower figure represents the entire set with 
injection pump arranged in aseptible metal case. 



214 



DECAPITATION. 



of the chisel firmly against the part with one hand in such 
a manner as to effectively guard the instrument from slip- 
ping aside and wounding the maternal organs, steady and 
direct the handle with the other hand and have an assistant 
drive the chisel by means of blows of proper vigor with the 
mallet into the bones of the face and head. Do not drive 
the chisel deeper than the length of the blade without stop- 
ping and forcibly revolving it upon its long axis and break- 
ing the foetal bones apart. The partially detached pieces of 
bone may be torn away with the fingers or in case the skin 
is quite adherent to them the bone may be held with the 
fingers of one hand, the chisel introduced with the other 
and using it as a spatula complete the separation. Repeat 
the use of the chisel as often as may be necessary in order 
to bring about the required diminution of the head, care 
being taken at all times not to wound the maternal parts 
and to conserve as far as practicable the skin of the fetal 
face and head in order that it may protect the maternal 
parts from the jagged bones during the passage of the re- 
mains of the head. The removal of the partially detached 
pieces of bone may in many cases be greatly facilitated by 
looping a cord over them and having an assistant apply 
traction sufficient to pull them away, the operator guarding 
the maternal organs by holding the piece of bone during its 
detachment and extraction, in the palm of his hand. 



47. DECAPITATION. 

Objects. The facilitation of repulsion and correction of 
the deviation of fetal parts. The operation is generally car- 
ried out when the fetal head is far advanced in the pelvic 
canal or has passed beyond the vulva. 

Technic. Attach a cord to the inferior maxilla or around 
the neck of the fetus and have one or more assistants draw 
the head out as far as possible. 



SUBCUTANEOUS AM PUT A TION. 2 1 5 

Some obstetrists have found difficulty in applying traction 
to the inferior maxilla by means of a cord. First make a 
perforating wound with the knife between the rami of the 
lower jaw, then carry the looped cord over the jaw and push 
it beyond the perforating incision with the loop resting 
within the mouth and finally pass the free end of the cord 
through the perforation from the buccal cavity outwards, 
and drawing upon this the inferior maxilla is so engaged 
that it will permit the application of powerful traction. 

Make a circular incision through the integument encir- 
cling the head at a convenient point and separate the skin 
backward toward the occiput by forcing the hand between 
it and the bones or by using the chisel as a spatula or 
dissecting it away with the Colin's scalpel, continuing the 
separation over the occiput to the atloid region. Make a 
transverse incision below across the trachea and oesophagus 
and surrounding muscles and above through the ligamentum 
nuchae. Grasp the head firmly with both hands and twist 
it forcibly on its long axis rupturing the articular ligaments 
and the remaining muscles and other soft tissues, detaching 
the head at the occipito-atloid articulation. The removal 
of the head greatly diminishes the bulk of the fetus and it 
may now be repelled, or deviated parts brought into the 
desired position or other operations performed. 



48. SUBCUTANEOUS AMPUTATION OF ANTERIOR LIMBS. 

Objects. Amputation of the anterior limbs is very 
frequently called for in obstetric practice especially in the 
mare, chiefly: in cases of transverse presentation with all 
four feet presenting and the head retained where it may be 
impossible to safely correct the deviation ; in cases of wry 
neck in the foal in the anterior presentation, when it is 
impossible to correct the deviation of the head, or in any 
case in the mare or cow where deviation of the head cannot 



2 1 6 SUBCUTANEOUS AM PUT A TION. 

be corrected or is not so readily overcome as is the amputa- 
tion of the limb. 

Technic. Our herbivorous animals being devoid 
of a clavicle, the anterior limb is attached to the thorax by 
means of the skin and muscles only and is therefore compar- 
atively easily amputated. Attach a cord to the pastern of 
the limb, the shoulder of which lies most exposed or is most 
readily reached and have one or two assistants exert traction 
on it and draw it out as far as possible with safety to the 
mother. Insert one hand armed with the hooked embry- 
otomy knife up to the top of the scapula or as nearly thereto 
as can be reached, the knife being well guarded in the palm 
of the hand which rests against the limb of the fetus ; press 
the knife into the skin and subcutaneous tissues and drawing 
the hand downward slit them freely and deeply from the top 
of the scapula down to the pastern. Lay aside the knife and 
force the fingers between the skin and subjacent tissues of 
the limb and while the assistant maintains gentle traction, 
separate the skin upward by forcing the hand or the ball of 
the thumb through the loose connective tissue until the 
upper region of the scapula is reached. The separation of 
the skin from the subjacent parts may require at certain 
points, like the olecranon or carpus, the aid of the chisel 
or knife to divide firm bands of connective tissue. This 
separation of the skin from the subjacent parts has removed 
the chief source of resistance to the tearing of the limb 
away from the body. The next most important obstacle is 
the pectoral muscles which should be torn asunder by sep- 
arating them into small bundles and tearing them through 
with the fingers between the sternum and limb, or the pro- 
cess may be aided by incision with a knife or the chisel. 
When these are well divided the remaining impediment to 
tearing the shoulder away consists largely of the trapezius 
and rhomboideus muscles at the top, the latissimus dorsi be- 
hind, the great serratus and the angularis scapula which 



SUBCUTANEOUS AMPUTATION. 



217 



only come into action when the shoulder is nearly severed. 
It is only necessary then to separate t^ie skin from the limb 
and divide the pectoral muscles in order to readily draw the 
limb away by traction. Divide the skin now around the 
pastern and have two or three assistants exert traction upon 
the limb while the operator places his hand against the 
sternum and pushes in the opposite direction. Or the op- 
erator may increase his repulsion by using the repeller and 
pushing upon the crutch with his hand while an assistant 
pushes upon the repeller handle. The impact upon the 
maternal organs due to the traction may be reduced to al- 
most any desired degree by applying a corresponding degree 
of repelling force to the sternum of the fetus. If the re- 
pelling force applied to the fetal sternum equals the traction 
upon the limb the impact of the fetus against the maternal 
organs becomes nil. 

If traction does not bring the limb away promptly the 
operator should attempt to extend the division of the 
muscles attaching the limb to the thorax while moderate 
traction upon the limb is continued. 

Further diminution of the size of the fetus may now be 
had by removal of the other limb in the same way which is 
especially desirable in the transverse presentation with all 
four limbs in the passages or we may reduce the size of the 
trunk by evisceration as described under 54. 

This diminution suffices to permit the remnant of the 
fetus to be withdrawn with the head deviated to the side, 
the total resistance being no greater than had the head and 
neck presented normally. It also renders the fetal body 
very flaccid, and easy of repulsion and simplifies the cor- 
rection of any deviations of parts. 



2i8 DETRUNCATION. 

49. AMPUTATION AT HUMERO-RADIAL ARTICULATION. 

Object. Amputation at this point is rarely desirable, but 
may at times be necessar}^ in the mare in order to remove 
an anterior limb when it is impossible, on account of the 
position to reach the shoulder. 

Technic. Attach a cord to the pastern and have an 
assistant render the leg tense by exerting moderate traction, 
as in the preceding. Introduce the hand armed with the 
embryotomy knife, carefully concealed in the palm, and 
girdle the skin around the articulation. Passing above the 
head of the olecranon on the posterior side, divide the 
attachment of the anconean group of muscles with the 
knife by cutting from behind forward. Then divide 
transversely, as far as possible, the muscles and ligaments 
passing over the articulation. Rotate the limb forcibly on 
its long axis while strong traction is maintained, and rup- 
ture the principal ligaments until the limb is completel}^ 
detached and comes away. In cases of limited room it may 
sometimes be easier to detach the skin of the limb from the 
pastern up to the articulation, as in the preceding chapter, 
rather than to girdle it. 



50. DETRUNCATION. 
Plate XXXVI. 

Object. In case a fetus in the anterior presentation and 
dorso-sacral position has one or both posterior limbs devi- 
ated forward and the feet engaged in or against the pelvis, it 
may be necessary, or at least advisable in the mare, that the 
trunk of the fetus be divided in order to bring about delivery 
without serious or fatal injury to the mother. 

Technic. Secure the two hind feet by means of cords, 
if possible, prior to other manipulations. Apply cords to 
the two anterior limbs and the head, have one or two assist- 
ants draw the anterior part of the fetus as far out as is prac- 
ticable and safe, and then girdle the fetal body immediately 







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222 DESTRUCTION OF THE PELVIC GIRDLE. 

against the maternal vulva by making an incision through 
the skin and skin muscle. If practicable it is best at this 
point to remove one shoulder subcutaneously, (48), and fol- 
low by evisceration, (54), in order to give greater opera- 
tive room and increased mobility of the fetus. Insinuate 
the hand between the skin and the deeper structures and 
forcibly separate the integument from the fetal body back- 
ward until the last rib is passed, as shown at the curved 
line in Plate XXXVI. Force the finger tips through the 
abdominal wall behind the last rib and passing along the 
entire border of each posterior rib, separate the abdominal 
walls from the ribs and sternum. After the abdominal 
muscles have been detached, and the fetus has been evis- 
cerated, rotate the thorax upon its long axis which 
will cause a division of the vertebral column near the dorso- 
lumbar articulation and the anterior portion of the fetus 
falls away. 

Secure the two posterior feet with cords, unless this has 
already been done, spread the detached skin, which has 
been pushed back from the thorax, carefully over the 
amputation stump of the lumbar vertebrae, repel these by 
means of the hand while an assistant draws upon the cords 
attached to the feet, push the remnant of the fetal trunk 
into the uterus and advance the feet along the genital pass- 
ages, thus converting it into a posterior presentation. 
Ordinarily this would result in a dorso-pubic — which 
should be converted into the dorso-sacral position, when 
its extraction can be readily brought about. 



51. DESTRUCTION OF THE PELVIC GIRDLE IN THE 
ANTERIOR PRESENTATION. 

Plate XXXVII. 

Object, [n somewhat rare instances perhaps most fre- 
quently in the cow the pelves of the mother and fetus be- 
come interlocked, the antero-external angle of the fetal 
ilium, r, becoming locked with the shaft of the maternal 



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2 26 A MPUTA TION OF THE L I MBS A T THE TA RSUS 

ilium I at C in such a manner that any safe degree of trac- 
tion fails to dislodge it. 

Technic. Remove one anterior limb subcutaneously, 
(48), and eviscerate, (54), through an opening made by 
the removal of two or three of the exposed ribs. Introduce 
the chisel through this opening and carry it back with the 
hand, place it against the shaft of the fetal ilium, I', have 
an assistant drive it through the shaft from before to behind 
and then withdrawing the chisel replace it against the pubic 
brim either at the symphysis pubis or opposite the obturator 
foramen, and drive it through the pubis and ischium at 
either of these points. The coxo-femoral articulation is thus 
detached and isolated so that the entire limb may drop 
backward beyond its fellow, the remnant of the severed 
ilium, I', can drop downward or move in any direction and 
the entire pelvis thus loses its rigidity and undergoes great 
diminution in size so that it can readily be withdrawn. 



52. AMPUTATION OF THE LIMBS AT THE TARSUS. 
Plate XXXVIII. 

Object. It sometimes happens in the mare, far more 
rarely in the cow that in the posterior presentation with the 
hind limbs retained at the hock owing to the unusual size 
of the fetus or its having been dead for some time, dry and 
emphysematous, that the deviation can not be overcome or 
its correction would entail an unnecessary amount of labor. 
In these cases it is frequently easier for the obstetrist and 
safer for the mother to amputate the limb at the tarsus. 

Technic. Pass a cord around the leg above the tarsus 
as indicated in Plate XXXVIII and have an assistant hold 
the leg steady by gentle traction. Introduce the chisel 
carefully guarded in the palm of the hand, and place it 
against the lower part of the tarsus as shown between T, T. 
The chisel should be placed as nearly as possible perpen- 







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2 30 IN TEA- PEL VIC AM PUT A TION. 

dicular to the long axis of the metatarsus. The proper direc- 
tion of the chisel may at times be greatly favored by placing 
the cord upon the metatarsus instead of the tibia thus forc- 
ing the tarsus toward the sacrum of the mother and tending 
to throw the metatarsus straight across the pelvic cavity. 
When the fetus is in the dorso-sacral position and it is 
desired to amputate the left limb, the chisel should be held 
in the palm of the left hand with its dorsal surface against 
the vaginal walls and the instrument carefully guarded and 
guided during the entire operation. The amputation should 
preferably be through the lower section of the tarsus but 
may be made through the head of the metatarsus. Do not 
drive the chisel entirely through the hock without removal 
as it may become caught and clamped between the divided 
bones, but drive for a few inches along the lateral side being 
sure that the skin at that point is severed along with the 
bone, then loosen the chisel by rotation and lateral motion 
and drive somewhat deeper into the tarsus until it is com- 
pletely severed. Withdraw the severed metatarsus and re- 
move any dangerous spicules of bone remaining on the 
stump and see that the latter is safely secured by a cord 
passing around the leg above the os calcis. Repeat the 
operation on the other hock in a similar manner using the 
right hand to guide the chisel. Extend the two limbs into 
the passages by traction and effect a posterior delivery. 

53. INTRA-PELVIC AMPUTATION OF THE POSTERIOR 
LIMBS, BREECH PRESENTATION. 

Plates XXXIX-XL. 

Uses. The overcoming of dystocia due to a posterior 
presentation with the hind limbs completely retained in the 
uterus, the so-called breech presentation, in cases where the 
deviation can not be readily corrected. 

Technic. Introduce one hand armed with the embry- 
otomy knife through the maternal passages until the peri- 

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234 INTRA-PEL VIC AMPUTA TION. 

neum of the fetus is reached and make a free incision 
through that region involving the anus in the male fetus 
and the anus and vulva in the female and enlarge the 
incision sufficiently to admit the operator's hand into the 
fetal pelvis. Locate the great sciatic ligament and with the 
knife divide the ligament from end to end, thus enlarging 
the pelvic cavity and giving ample operating room. If the 
pelvis of the fetus is too small to admit the hand of the 
operator at all before severing the sciatic ligament, this 
may be accomplished by cautiously cutting from behind 
forward with Colin's scalpel or with the chisel. When this 
has been severed and sufficient operating room attained, 
carry the chisel with the hand and place it against the shaft 
of the ilium as shown between I' I' in Plate XXXIX as 
nearly perpendicular to the long axis of the iliac shaft as 
possible and keeping the hand in touch with the chisel blade, 
have an assistant drive it through the bone until it and its 
periosteum are completely severed. Revolve the chisel on 
its long axis and force the cut ends of the bone apart. Dis- 
engage the chisel and place it against the symphysis pubis 
or against the ischium opposite the obturator foramen and 
drive it through the ischium and pubis at this point. Using 
the chisel as a lever, separate the isolated portion of the 
pelvis as completely as practicable from the surrounding 
tissues, and with the fingers separate the muscles from the 
detached pelvic bone for a short distance from the severed 
ends on either side. Carry a cord in, pass the loop over the 
ends of the severed section and tightening it secure the iso- 
lated portion of the pelvis and have one or more assistants 
exert traction as indicated in Plate XL. The chief 
obstacle to the withdrawal of the limb is the great gluteus 
muscle which should be sought for, identified and torn 
through with the fingers at a distance of 5 or 6 cm. from 
its attachment to the great trochanter. Other important 
points of resistance are the attachment posteriorly of the 
skin, vulva and anus to the ischium through the medium 






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238 INTRA- PEL VIC A MPUTA TION. 

of aponeurosis and anteriorly, chiefly on the median line, 
the prepubic tendon ; these are to be cut, if necessary, with 
the chisel or knife. Vigorous traction may now be applied 
by means of the cord, the operator in the meantime guard- 
ing the most advanced end of the detached piece of pelvis 
with the palm of his hand in order to prevent injury to the 
maternal organs. Sometimes this detached piece of the 
pelvis tears away from the femur when traction is applied 
and comes away alone. In such a case the cord is to be 
applied over the head and trochanter of the femur and 
traction again applied drawing the limb away in a reversed 
position, the skin being turned back or everted as it ad- 
vances until the region of the hock is reached where the 
integument does not so readily separate and only requires 
to be cut loose and the member allowed to come away. 
During the removal of the limb the operator is to con- 
stantly note the progress with his hand and sever by tearing 
or cutting any tendons or muscles which offer special 
obstruction to the operation. Repeat the operation upon 
the opposite limb in the same manner except that but one 
incision need be made through the bone, that is, through 
the shaft of the ilium. During the entire work the opera- 
tion is carried out subcutaneously or rather intra-fetally 
and the maternal parts are amply guarded against injury. 
The size of the fetal trunk may be further reduced if de- 
sirable, by evisceration, (54), and followed still further by 
the introduction of the chisel guided by the hand and the 
ribs, on one or both sides, severed one after another until 
the chest can completely collapse. Or the ribs may be yet 
more conveniently severed by introducing the sector in the 
body cavity, pushing it forward until the first rib is reached 
catching the spherical end over the rib and drawing back- 
wards, sever each rib in turn. If need be some of these 
may be removed and one of the anterior limbs caught by a 
cord around the scapula and extracted intra-fetally. The 
remnant of the fetus is to be extracted by means of a cord 
fastened about the lumbar region of the spine. 



EVISCERATION. 239 

54. EVISCERATION. 

Evisceration of the fetus is frequently desirable in ob- 
stetric practice and has a variety of uses. It decreases the 
size of the fetal trunk considerably and permits its more 
ready passage through the genital canal, as in the anterior 
presentation ; with lateral deviation of the head it renders 
the fetal trunk flaccid through the removal of the viscera 
supporting the body walls and permits the body remnant to 
be bent or moved more readily for the correction of any mal- 
presentation ; it permits freedom of intra-fetal operations 
directed against other parts, as for detruncation, or for the 
destruction of the pelvic girdle in the anterior presentation, 
and when a fetus is emphysematous, evisceration permits 
the gases of decomposition to pass into the fetal body cavity 
and thence externally. The escape of gases is very greatly 
favored further by the cutting of the ribs. 

Technic. Evisceration may be variously performed, but 
is generally demanded in either the anterior or posterior 
presentation and a description of these will suffice. 

In the anterior presentation, unless the fetus is far ad- 
vanced through the vulva, evisceration is best performed by 
the removal of one or more of the anterior ribs. The ribs 
are generally best reached by the removal of the shoulder, 
as already described under subcutaneous amputation of the 
anterior limbs, (48). When the ribs have been laid bare in 
the manner described the operator can thrust the finger tips 
through the intercostal muscles in the first space and enlarge 
the opening thus made by tearing through the muscles up- 
wards to the spinal column and downwards to the sternum ; 
then grasping the posterior border of the rib near its middle, 
fracture it by means of a sudden and vigorous pull. The 
fractured ends may then be grasped and pulled, broken or 
twisted off. The chisel may be brought into use if required 
in order to divide the rib, the hand of the operator con- 
stantly guiding and guarding the chisel blade. The opera- 



240 E VISCERA TION. 

tion is then to be repeated if required, upon the second and 
third ribs in the same manner until an opening into the 
chest is secured ample in size for the introduction of the 
operator's hand. 

Force one hand through the opening and tear the medi- 
astium above and below from the thoracic walls, and then 
grasp either the trachea at its bifurcation or the heart and 
tear them awa3^ The heart, which constitutes the greater 
bulk of the thoracic viscera, is best grasped in the palm of 
the hand, with the fingers engaging the aorta and pulmo- 
nary arteries. When the thoracic viscera have been with- 
drawn, thrust the fingers through the diaphragm and locat- 
ing the liver, isolate the diaphragmatic area to which it is 
attached, and engaging both with the fingers remove the two 
together. The liver constitutes, in a normal fetus, the chief 
intra-abdominal mass, occupjnng more space than all other 
organs combined. After the liver has been removed the 
intestinal tube, with its contents, is withdrawn without 
difficulty, as its attachments are feeble. The kidneys may 
also be removed. 

Evisceration in the posterior presentation is preferably 
performed through the pelvis, generally in connection with 
intra- pelvic amputation of the posterior limbs, (53). It 
may be performed without destruction of the pelvic girdle 
by making an incision through the perineal region and 
then severing the sacro-sciatic ligament as directed under 
53. When admission has been gained to the abdominal 
cavity introduce the hand and withdraw the alimentary 
tube, then rupture the diaphragm about the liver and 
tear away the latter organ in the same manner as in the 
anterior presentation. The liver is so friable that it cannot 
well be removed by grasping the organ itself, but comes 
away entire with the central part of the diaphragm. 

Remove the heart and lungs as above directed. 



\ 



JUN 21 1912 



